Vol. 11 No. 1 (2023)

Archives of Academic Emergency Medicine Volume 10, Number 1 (2022) Identification Data

Frequency: Continuous volume

ISSN-online: 2645-4904

Editorial Team:

Editor-in-chief: Prof. Iraj Najafi

Chairman and Deputy Editor: Dr. Saeed Safari

Editorial Board: Dr. Sukhminder Jit Singh Bajwa, Prof. Gianfranco Cervellin, Dr. Süleyman Türedi, Prof. Bruno Mégarbane, Dr. Mostafa Alavi-Moghaddam, Dr. Afshin Amini, Dr. Ali Arhami Dolatabadi, Dr. Ali Bidari, Dr. Hojjat Derakhshanfar, Dr. Mohammad Hossein Forouzanfar, Dr. Hamid Reza Hatamabadi, Prof. Jalil Hosseini, Prof. Mostafa Hosseini, Dr. Mohammad Jalili, Dr. GholamReza Oskrochi, Dr. Hamid Shokoohi, Dr. Hossein Alimohammadi, Dr. Alireza Baratloo, Dr. Mohammad Mehdi Forouzanfar, Dr. Alireza Majidi, Dr. Ali Shahrami, Dr. Majid Shojaee

Editorial Manager: Dr. Mahmoud Yousefifard

Journal Manager: Somayeh Saghaei Dehkordi

Language Editor: Mehrnoosh Yazdanbakhsh

Publisher: SBMU Journals

Owner: Treata Scholars

Principal & Support Contact: Somayeh Saghaei Dehkordi, ma.saghaei63@gmail.com, jemerg@sbmu.ac.ir 00982122721155

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This journal is distributed under the terms of CC BY-NC 3.0. Design and publishing by SBMU journals.

Original/Research Article

Effects of Pre-Hospital Dexamethasone Administration on Outcomes of Patients with COPD and Asthma Exacerbation; a Cross-Sectional Study

Thongpitak Huabbangyang, Agasak Silakoon, Chunlanee Sangketchon, Jareeda Sukhuntee, Jukkit Kumkong, Tanut Srithanayuchet, Parinya Chamnanpol, Theeraphat Meechai (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e56

Introduction: Chronic obstructive pulmonary disease (COPD) and asthma exacerbation are two common emergency situations. This study aimed to investigate the impact of pre-hospital dexamethasone initiation on treatment outcomes of these patients.

Methods: In this retrospective cross-sectional and comparative study, data from the emergency medical service (EMS) care report of patients with a final diagnosis of asthma or COPD, coded with Thailand's emergency medical triage protocol, collected between January 1, 2021, and October 31, 2022, were used. Data on baseline characteristics, emergency department length of stay (ED-LOS), and hospital admission rates were collected from electronic medical records and compared between cases with and without pre-hospital dexamethasone administration by EMS.

Results: 200 patients with COPD (n = 93) and asthma (n = 107) exacerbation were enrolled. The dexamethasone-treated group had a lower but statistically non-significant hospital admission rate (71.0% versus 81.0%, absolute difference: −10%, 95% confidence interval (CI): −21.76, 1.76; p = 0.100). In patients with asthma, the dexamethasone-treated had lower median ED-LOS time (235 (IQR: 165.5–349.5) versus 322 (IQR: 238–404) minutes; p = 0.003). Dexamethasone-treated asthma patients had lower but statistically non-significant hospital admission rates (60.4% versus 78.0%, absolute difference: −17.55%, 95% CI: −34.96, −0.14; p = 0.510). In COPD patients the dexamethasone-treated and untreated groups had non-significantly lower hospital admission rates (80.8% versus 85.40%, absolute difference: −4.60%, 95% CI: −19.82, 10.63; p = 0.561) and non-significantly lower ED-LOS (232 (IQR: 150 – 346) versus 296 (IQR: 212 – 330) minutes, absolute difference: −59 (−130.81, 12.81); p = 0.106).

Conclusion: The dexamethasone administration by EMS in pre-hospital setting for management of asthma and COPD patients is beneficial in reducing the ED-LOS and need for hospital admission but its effects are not statistically significant, except regarding the ED-LOS of asthma exacerbation cases.

Leuko-Glycemic Index in the Prognosis of Acute Myocardial Infarction; a Cohort Study on Coronary Angiography and Angioplasty Registry

Roxana Sadeghi, Mohammad Haji Aghajani, Reza Parandin, Niloufar Taherpour, Koohyar Ahmadzadeh, Arash Sarveazad (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e63

Introduction: The leuko-glycemic index (LGI), a combined index of patient leukocyte counts and blood glucose levels, has been shown to predict the prognosis of myocardial infarction (MI) patients. Our study aims to investigate the performance of LGI in prediction of outcomes in a population of diabetic and non-diabetic MI patients.

Methods: This observational registry-based cohort study was performed on acute myocardial infarction (AMI) patients. Participants were sub-grouped according to their diabetes status and the calculated optimal LGI cut-off value. The outcomes of the study were the length of hospital stay, and in-hospital and 30-day mortality.

Results: A total of 296 AMI (112 diabetic and 184 non-diabetic) patients were included in the study. The optimal cut-off value of LGI in the diabetic and non-diabetic groups was calculated as 2970.4 mg/dl.mm3 and 2249.4 mg/dl.mm3, respectively. High LGI was associated with increased hospital admission duration in non-diabetic patients (p = 0.017). The area under the curve (AUC) of LGI for prediction of in-hospital mortality was 0.93 (95% CI: 0.87 to 1.00) in the diabetic group and 0.92 (95% CI: 0.85 to 0.99) in the non-diabetic group. LGI had a sensitivity and specificity of 90.00%, and 93.14% in prediction of in-hospital mortality in the diabetic group compared to 77.77% and 90.85% in the non-diabetic group. We observed 4 post-discharge mortalities in our patient group.

Conclusion: Our study demonstrated that higher LGI predicts in-hospital mortality in both diabetic and non-diabetic patients, while the length of hospital stay was only predicted by LGI levels in non-diabetic patients.

Characteristics and Outcomes of Patient Transport to the Hospital by Emergency Medical Services (EMS); a Cross-sectional Study

Pariwat Phungoen, Lap Woon Cheung, Kamonwon Ienghong, Korakot Apiratwarakul (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e69

Introduction: To enhance the efficiency, it is essential to understand the patterns of service users and develop policies that facilitate effective personnel and resource management. This study aimed to compare the characteristic and outcomes of patients who were transferred to emergency department (ED) by emergency medical services (EMS) and patients transported by other means.

Methods: This retrospective cross-sectional study was conducted at Srinagarind Hospital, Thailand, over a 5-year period from 2017-2021. The baseline characteristics, treatment modalities, and outcomes of patients who were transported to ED using EMS and Non-EMS were gathered and compared using STATA software.

Results: The study included 15,501 patients with the median age of 51 (interquartile range (IQR): 23-71) years who were referred by EMS over the five-year period (51.72% male). EMS patients had significantly higher median age (51 (23 - 71) vs. 37 (21 - 60); p < 0.001) with male preference (p < 0.001). In the EMS group, the triage level 1 (need for resuscitation) was higher than the non-EMS group (p < 0.001), most of the patients referred following trauma (p < 0.001), and the frequency of cardiac arrest was considerably higher than non-EMS group (2.54% vs 0.05%; p < 0.001). Patients in the EMS group received a higher number of blood tests (p < 0.001), plain radiographic exams (p < 0.001), computerized tomography (CT) scans (p < 0.001), and complex procedures (p < 0.001) than the non-EMS group. The EMS group had a greater number of hospital admissions (p < 0.001) and intensive care unit (ICU) admissions (p < 0.001) compared to the non-EMS group. The EMS group exhibited a significantly higher mortality rate compared to the non-EMS group (p < 0.001).

Conclusion: The population utilizing EMS services had higher median age, higher frequency of emergency cases and trauma related complaint, higher need for treatment interventions and imaging procedures, higher rate of hospital and ICU admissions, as well as higher rate of mortality compared to the non-EMS group.

Comparing Ultrasonography and Surface Landmark-Guided Lumbar Puncture in Patients with Obesity and Difficult Anatomy; a Randomized Controlled Trial

Pitsucha Sanguanwit, Phantakan Tansuwannarat, Chinnarat Bua-Ngam, Supakrid Suttabuth, Pongsakorn Atiksawedparit, Satariya Trakulsrichai (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e59

Introduction: Previous studies have shown higher lumbar puncture (LP) success rates when using ultrasound guidance. This study aimed to compare the first-attempt success rate of ultrasound-guided LP with blind technique of needle insertion using the palpable spinal surface landmark in patients with obesity or a difficult anatomy.

Methods: This prospective randomized controlled study was performed at the emergency department of Ramathibodi Hospital, an academic tertiary university hospital, from August 2015 to July 2016.

Results: 40 patients were enrolled (20 surface landmark-guided and 20 ultrasound-guided LPs). 52.5% of the patients were male with the mean age of 60.33 ± 4.24 years. The first-attempt success rate in the ultrasound-guided LP group was significantly higher than the landmark-guided LP group (80% vs. 35%, respectively), with risk difference (RD) of 45.00% (95% confidence interval (CI): 17.72%, 72.28%). This indicated absolute risk reduction and number needed to treat of 45.00% and 2.22, respectively. The median procedural duration required to achieve successful LP in the ultrasound-guided LP group was significantly shorter than the surface landmark-guided LP group (5 [IQR: 3–18] minutes vs. 13.5 [IQR: 5-30] minutes, respectively). Traumatic puncture as a complication occurred less frequently in the ultrasound-guided LP group than the surface landmark-guided LP group with risk ratio (RR) = 0.33 (95% CI: 0.08, 1.46) and RD = -20.00% (95% CI: -44.00%, 4.00%). This indicated absolute risk reduction and number needed to harm of 20.00% and 5.00, respectively. However, the difference was not significant.

Conclusion: Using ultrasound to help localize the insertion point before LP increased the first-attempt success rate and improved other LP outcomes in Thai patients with obesity or a difficult anatomy. It also shortened the procedural duration and reduced the incidence of traumatic tap.

Mental Health Triage from the Viewpoint of Psychiatric Emergency Department Nurses; a Qualitative Study

Fatemeh Rajab Dizavandi, Razieh Froutan, Hossein Karimi Moonaghi, Abbas Ebadi, Mohammad Reza Fayyazi Bordbar (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e70

Introduction: Mental health triage is a new nursing practice concept that is less studied and defined, especially among Iranian nurses. Therefore, this study aimed to explain the concept of mental health triage from the perspective of psychiatric emergency department (ED) nurses.

Methods: This qualitative study collected data using semi-structured interviews with psychiatric ED nurses. Sampling was purposive and continued until data saturation. Analysis was conducted using conventional content analysis, as described in Griesheim and Landman approach.

Results: 15 psychiatric ED nurses with the mean age of 35.13 ± 8.44 years were interviewed (60% male). Finally, two themes, five categories, and 16 sub-categories emerged from data analysis. Two themes emerged, including mental health triage meaning and mental health triage structure. The former included two categories of the nature and characteristics of mental health triage, and the latter consisted of three categories of mental state exploration from surface to depth, safety control measures, and the degree of emergency. According to the "degree of emergency" category, nurses could not make triage decisions based on their perceptions in an acceptable way.

Conclusion: Psychiatric ED nurses have an appropriate understanding of mental health triage meaning. However, according to these nurses, its structure is associated with shortcomings that limit the provision of mental health triage services and reduce their quality.

Basic Life Support (BLS) Knowledge Among General Population; a Multinational Study in Nine Arab Countries

Nour Shaheen, Ahmed Shaheen, Rehab Adel Diab, Abdelrahman Mohmmed, Abdelraouf Ramadan, Sarya Swed, Muhannad Wael, Mrinmoy Kundu, Sama Soliman, Mohamed Elmasry, Sheikh Shoib (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e47

Introduction: Basic Life Support (BLS) is a medical treatment used in life-threatening emergencies until the sufferer can be properly cared for by a team of paramedics or in a hospital. This study aimed to assess the level of knowledge regarding BLS and the contributing factors among the Arab non-medical population.

Methods: An online survey-based cross-sectional study was conducted among non-medical populations in nine Arab countries between April 13, 2022, and June 30, 2022. The utilized questionnaire consisted of two parts: part one included socio-demographic characteristics and part two measured knowledge of BLS through an online survey.

Results: The research included a total of 4465 participants. 2540 (56.89%) of the participants were knowledgeable about BLS. The mean basic life support knowledge scores of participants who received training were higher than those who had not (20.11 ± 4.20 vs. 16.96 ± 5.27; p< 0.01). According to the nations, Yemen scored the highest, while Morocco had the lowest levels of BLS knowledge (19.86 ± 4.71 vs. 14.15 ± 5.10, respectively; p< 0.01). Additionally, individuals who resided in urban areas scored on average higher than those who did in rural areas (17.86 ± 5.19 vs. 17.13 ± 5.24, p= 0.032) in understanding basic life support. Age, information sources, and previous training with theoretical and practical classes were significant predictors of BLS knowledge.

Conclusion: The level of BLS knowledge among non-medical people in Arab nations is moderate but insufficient to handle the urgent crises that we face everywhere. In addition to physicians being required to learn the BLS principles, non-medical people should also be knowledgeable of the necessary actions to take in emergency events.

Associated Factors of Under and Over-Triage Based on The Emergency Severity Index; a Retrospective Cross-Sectional Study

Thongpitak Huabbangyang, Rapeeporn Rojsaengroeng, Gawin Tiyawat, Agasak Silakoon, Alissara Vanichkulbodee, Jiraporn Sri-on, Siriwimol Buathong (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e57

Introduction: Under-triage increases patients’ risks for morbidity and mortality, whereas over-triage limits the resources available to sicker patients. This study aimed to determine the rates as well as associated factors of under-triage and over-triage in emergency department (ED), based on Emergency Severity Index (ESI) triage system.

Methods: In this retrospective cross-sectional study, triage level of ED patients based on the ESI version 4, was studied during a 9-month period in 2019. Patients’ ESI level, which were examined by triage nurses were reevaluated by 3 emergency physicians and the rate of correct, under-, and over-triage as well as their associated factors were analyzed.

Results: 1000 cases of triage were evaluated. Triage was correct in 69.1% of cases. The rate of under-triage was 4.9%, and that of over-triage was 26.0%. Over-triage was significantly more common among patients aged 18–30 years than for those aged ≥65 years (adjusted odds ratio [OR] = 1.73; 95% confidence interval [CI]: 1.07–2.81; p = 0.026); those with traumatic injuries (adjusted OR = 1.80; 95% CI: 1.29–2.52; p = 0.001); those arriving at the hospital during the evening shift (adjusted OR = 1.42; 95% CI: 1.01–2.0; p = 0.046); patients who were hospitalized (adjusted OR = 0.35; 95% CI: 0.22–0.54; p < 0.001); and those with severe pain (adjusted OR = 0.28; 95% CI: 0.10–0.84; p = 0.023). Younger age was also significantly associated with under-triage. Patients aged 18–30 years were under-triaged more often than those aged ≥65 years (adjusted OR = 3.05; 95% CI: 1.16–8.00; p = 0.023).

Conclusions: Over-triage was substantially more common than under-triage in Vajira Hospital. Factors associated with over-triage were younger age, traumatic injury, arrival time, hospital admission, and severe pain. Younger age was the only factor related to under-triage.

Haloperidol-Midazolam vs. Haloperidol-Ketamine in Controlling the Agitation of Delirious Patients; a Randomized Clinical Trial

Mehrad Aghili, Hamidreza AkhavanHejazi, Zeinab Naderpour, Elnaz Vahidi, Morteza Saeedi (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e61

Introduction: Agitation management in delirious patients is crucial in a crowded emergency department (ED) for both patient and personnel safety. Benzodiazepines, antipsychotics, and newly derived ketamine are among the most commonly used drugs in controlling these cases. This study aimed to compare the effectiveness of haloperidol-midazolam with haloperidol-ketamine combination in this regard.

Methods: In this double-blind randomized clinical trial, delirious patients with agitation in ED were randomly assigned to a group: group A: haloperidol 2.5 mg IV and midazolam 0.05 mg/kg IV or group B: haloperidol 2.5 mg IV and ketamine 0.5 mg/kg IV. Sedative effects as well as side effects at 0, 5, 10, 15, 30 minutes and 1, 2, 4 hours after the intervention were compared between the 2 groups.

Results: We enrolled 140 cases with Altered Mental Status Score (AMSS)≥+2 and mean age of 52.8±19.4 years (78.5% male). Agitation was significantly controlled in both groups (p<0.05). In group B, AMSS score was more significantly and rapidly reduced 5 (p = 0.021), 10 (p = 0.009), and 15 (p = 0.034) minutes after drug administration. After intervention, oxygen saturation was significantly decreased in group A 5 (p = 0.031) and 10 (p = 0.019) minutes after baseline. Time required to the maximum effect was significantly lower in group B versus group A (p=0.014). Less patients in group B had major side effects (p=0.018) and needed physical restraint (p=0.001).

Conclusions: Haloperidol-ketamine can control agitation in delirium more rapidly than haloperidol-midazolam. This combination had lower adverse events with lower need for physical restraint.

Accuracy of Pain Scales in Predicting Critical Diagnoses in Non-Traumatic Abdominal Pain Cases; a Cross-sectional Study

Supapilai Ueareekul, Chanon Changratanakorn, Parinya Tianwibool, Nattikarn Meelarp, Wachira Wongtanasarasin (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e68

Introduction: Accurate assessment and management of abdominal pain in the emergency department (ED) is crucial, as it can indicate potentially life-threatening conditions requiring timely treatment. This study aimed to evaluate the ability of pain scales to predict critical diagnoses in patients with non-traumatic abdominal pain.

Methods: This cross-sectional study was conducted at a tertiary university hospital and involved individuals aged 15 years and above who presented to the ED with non-traumatic abdominal pain. Pain severity was evaluated using subjective pain scales, including the Numerical Rating Scale (NRS) and the Face Pain Scale (FPS), as well as objective pain scales, including the Critical Care Pain Observation Tool (CPOT) and the Non-verbal Pain Score (NVPS). The area under the receiver operating characteristic curve (AuROC) was employed to determine the discriminative ability of each pain scale to predict critical diagnosis.

Results: 264 cases with the mean age of 47.2±19.4 years were studied (53.0% male). The most common location of abdominal pain was epigastric pain (43.9%). Most patients presented with dull-aching pain, and those with critical diagnoses had more of this characteristic than those with non-critical diagnoses. (52.5% vs. 28.3%, p = 0.01). The overall median NRS, FPS, CPOT, and NVPS of included participants were 8 (interquartile range (IQR) 7-10), 8 (IQR 6-8), 3 (IQR 1-4), and 3 (IQR 2-4), respectively. Patients with critical diagnoses had a higher NVPS score than patients with non-critical diagnoses (median score of 4 vs. 3, p = 0.02). The AuROC of NRS, FPS, CPOT, and NVPS were 0.53 (95% CI: 0.45-0.62), 0.55 (95% CI: 0.46-0.63), 0.59 (95% CI: 0.50-0.68), and 0.62 (95% CI: 0.53-0.71), respectively. The correlation coefficients among these scales were considered moderately correlated or higher.

Conclusion: In evaluating patients with non-traumatic abdominal pain, the NVPS demonstrated the highest accuracy in predicting critical diagnoses. However, all pain scales, whether subjective or objective, exhibited suboptimal performance in predicting critical diagnoses.

Mapping Global Research in Emergency Medicine; a Bibliometric Analysis of Documents Indexed in the Web of Science Database

Saeid Golfiruzi, Mohsen Nouri, Fatemeh Sheikhshoaei, Farzaneh Fazli, Nahid Ramezanghorbani, Mohammad Mahboubi, Masoud Mohammadi (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e53

Introduction:Emergency medicine is a relatively new and rapidly growing specialty, and its research monitoring is important for future policies. This study aimed to analyze the published literature related to emergency medicine, to create a documented research perspective for this field.

Methods: This research is a bibliometric study that analyzes the research outputs of the subject area of emergency medicine indexed in the Web of Science database from the beginning to 2023. VOSviewer software was used to visualize and predict the trends in research on the topic.

Results: The findings showed that the University of California, The Journal of Neurotrauma and Brain Injury, Elsevier, and the USA were the most prolific units in the cycle of scientific productions in the field of emergency medicine. Results showed that most scientific productions in this field fall into 6 clusters: psychological impressions, injuries caused by traumatic events and the effects of traumas on children, pathophysiology and nervous system issues and related diseases, complications of traumatic events and injuries, biomechanics and complications caused by sports injuries, and consciousness.

Conclusion: In addition to interventions and clinical complications, research in the field of emergency medicine has also focused on psychological structures. So, based on various measurement indicators, the subjects of this field have been the focus of researchers' attention.

Pre-hospital Prognostic Factors of 30-Day Survival in Sepsis Patients; a Retrospective Cohort Study

Thongpitak Huabbangyang, Rossakorn Klaiangthong, Fahsai Jaibergban, Chanathip Wanphen, Thanakorn Faikhao, Passakorn Banjongkit, Ratchaporn Kuchapan (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e48

Introduction: According to excising findings, if the emergency management system (EMS) operation will be developed, the survival outcome of sepsis patients might improve. This study aimed to evaluate the pre-hospital associated factors of survival in sepsis patients.

Methods: This retrospective cohort study was conducted on patients diagnosed with sepsis, coded with the Thailand emergency medical triage protocol and criteria-based dispatch symptom group 17. Information on the 30-day survival rate of patients was obtained from the electronic medical records. Pre-hospital factors associated with 30-day survival were analyzed using univariate and multivariate logistic regression analyses and were reported using odds ratio (OR) with 95% confidence interval (CI).

Results: 300 patients diagnosed with sepsis were enrolled. Among them, 232 (77.3%) survived within 30 days. Non-survived cases had significantly older age (p = 0.019), lower oxygen saturations (92.5% vs. 95.0%; p = 0.003), higher heart rate (p = 0.001), higher respiratory rate (p < 0.001), lower level of consciousness (p < 0.001), higher disease severity based on qSOFA score (p = 0.001), and higher need for invasive airway management (p = 0.001) and supplementary oxygen (p = 0.001). The survival rate improved by 3.5% with every 1% increase in pre-hospital oxygen saturation (adjusted OR = 1.035, 95% CI: 1.005–1.066, p = 0.020) and the survival probabilities of patients who responded to voice (adjusted OR = 0.170, 95% CI: 0.050–0.579, p = 0.005), those who responded to pain (adjusted OR = 0.130, 95% CI: 0.036–0.475, p = 0.002), and those who were unresponsive (adjusted OR = 0.086, 95% CI: 0.026–0.278, p-value < 0.001) were lower than patients who were alert.

Conclusion: The 30-day survival rate of patients with sepsis managed by the EMS team was 77.3%. Pre-hospital oxygen saturation and level of consciousness were associated with the survival of patients with sepsis who were managed in the pre-hospital setting.

Periosteal Nerve Block Vs. Intravenous Morphine in Pain Relief of Distal Radius and Ulna Fracture; a Double-Blind Randomized Clinical Trial

Shadi Ashtari, Alireza Hasanzadeh, Alireza Bahmani, Ali Abdolrazaghnejad (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e51

Introduction: Distal forearm fractures’ realignment and fixation is a painful procedure. This study aimed to compare the efficacy of periosteal nerve block and intravenous morphine in distal radius and ulna fractures’ pain management.  

Methods: In the present randomized, parallel, double-blind, controlled clinical trial, patients with distal radius or ulna fractures were divided into two groups. In the first group, for periosteal nerve block, 1% lidocaine was injected at a distance of 6 to 8 cm near the wrist from the lateral radius and medial ulna. In the second group, morphine sulfate at a dose of 0.1 mg/kg was slowly injected through the peripheral vein within 5 minutes. The visual analog scale (VAS) score was evaluated before the intervention and every 15 minutes until 90 minutes after the intervention and was compared between the two groups.

Results: 75 subjects were studied (39 in the periosteal nerve block and 36 in the intravenous morphine group). There were no significant differences between the groups in terms of mean age (p = 0.384), gender distribution (p = 0.464), past medical history (p = 0.106), trauma type (p = 0.836), fracture type (p = 0.613), and baseline pain severity on VAS (p = 0.987). Both methods reduced the VAS scores during the 90 minutes of the study. The mean pain scores of the patients in the periosteal nerve block group with 2.56±1.44, 2.15±1.11, 2.66±1.26, and 3±1.27 at 15, 30, 45, and 60 minutes after the analgesic injection, respectively, were significantly lower than those of the intravenous morphine group  with 4.75±1.27, 4.22±1.22, 3.97±1.27, and 4.13±1.35, respectively (p < 0.001 for all comparisons). In the present study, no local or systemic complications were observed in the periosteal nerve block group, while the complications of dyspnea, vomiting, and pruritus were reported by 5.5%, 2.8%, and 2.8%, respectively, in the intravenous morphine group. Moreover, the percentage of need for additional analgesia in the intravenous morphine group was higher than that of the periosteal nerve block group.

Conclusion: In the first hour after the intervention, pain reduction in periosteal block was significantly higher than intravenous morphine administration. Also, the incidence of complications and the need for additional analgesia were lower in the periosteal block group compared to intravenous morphine administration.

Extracting the Factors Affecting the Survival Rate of Trauma Patients Using Data Mining Techniques on a National Trauma Registry

Mehdi Nasr Isfahani, Nahid tavakoli, Hossein Bagherian, Neda Al Sadat Fatemi, Mohammad Sattari (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e1

Introduction: Thousands of people die due to trauma all over the world every day, which leaves adverse effects on families and the society. The main objective of this study was to identify the factors affecting the mortality of trauma patients using data mining techniques.

Methods: The present study includes six parts: data gathering, data preparation, target attributes specification, data balancing, evaluation criteria, and applied techniques. The techniques used in this research are all from the decision tree family. The output of these techniques are patterns extracted from the trauma patients dataset (National Trauma Registry of Iran). The dataset includes information on 25,986 trauma patients from all over the country. The techniques that were used include random forest, CHAID, and ID3.

Results: Random forest performs better than the other two techniques in terms of accuracy. The ID3 technique performs better than the other two techniques in terms of the dead class. The random forest technique has performed better than other techniques in the living class. The rules with the most support, state that if the Injury Severity Score (ISS) is minor and vital signs are normal, 98% of people will survive. The second rule, in terms of support, states that if ISS is minor and vital signs are abnormal, 93% will survive. Also, by increasing the threshold of the patient's arrival time from 10 to 15 minutes, no noticeable difference was observed in the death rate of patients.

Conclusion: Transfer time of less than ten minutes in patietns whose ISS is minor, can increase the chance of survival. Impaired vital signs can decrease the chance of survival in  traffic accidents. Also, if the ISS is minor in non-penetrating trauma, regardless of vital signs and if the victim is transported in less than ten minutes, the patient will survive with 99% certainty.

A Clinical Score for Predicting the Paroxysmal Supraventricular Tachycardia’s Recurrence Risk; a Retrospective Cross-sectional Study

Chaiyaporn Yuksen, Welawat Tienpratarn, Rungrawin Promkul, Chetsadakon Jenpanitpong, Sorawich watcharakitpaisan, Jenjira Yaithet, Viruji Phonphom (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e2

Introduction: Identifying prognostic variables associated with the probability of recurrent paroxysmal supraventricular tachycardia (PSVT) would aid decision-making regarding disposition of the patients. This study aims to develop a clinical scoring system to predict PSVT recurrence after adenosine administration in the emergency department (ED).

Methods: This retrospective cross-sectional study was conducted on patients who were referred to the emergency department of Ramathibodi Hospital, a university-affiliated super-tertiary care hospital in Bangkok, Thailand, with diagnosis of PSVT during a 10-year period from 01 January 2010 until 31 December 2020. The cases were divided into recurrent and non-recurrent PSVT based on the response to standard treatment and the independent predictors of recurrence were studied using multivariable logistic regression analysis.

Results: 264 patients were diagnosed with PSVT and successfully converted by adenosine. 24 (9.1%) had recurrent PSVT, and 240 (90.9%) had no recurrent PSVT in the same ED visit. The risk of PSVT recurrence in ED corresponded with the history of hypertension (p = 0.059), valvular heart disease (p = 0.052), heart rate ≥ 100 (p = 0.012), and systolic blood pressure < 100 after electrocardiogram (ECG) converted to sinus rhythm (p = 0.022) and total dose of adenosine (p = 0.002). We developed a clinical prediction score of PSVT recurrence with an accuracy of 79.5%. A score of 0 (low risk), 1–2 (moderate risk), and > 2 (high risk) had a positive likelihood ratio (LR+) of 0.31, 0.56 and 2.33, respectively.

Conclusion: It seems that, using the PSVT recurrence score we could screen the high-risk patients for PSVT recurrence (score>2) who need to be observed for at least 6-12 hours and receive cardiologist consultation in ED. In addition, the moderate and low-risk group (score 0-2) need to be observed for 1 hour and can be discharged from ED.

Level of Self-Care and Patient Care Against COVID-19 Among Emergency Medical Services Personnel; a Cross-sectional Study

Sirvan Abbasi Ghocham, Sina Valiee, Naser Kamyari, Salam Vatandost (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e4

Introduction: Provision of pre-hospital care by emergency medical services (EMS) requires paying attention to self-care and patient care against possible infections. The present study was conducted with the aim of determining the level of self-care and patient care against COVID-19.

Methods: The present correlational, descriptive, analytical study was carried out on 301 EMS personnel in Iran. Data were collected using a demographic information form and questionnaires made by the researcher on the level of self-care and patient care against COVID-19.

Results: The results showed that more than half of the participants (55%) were aged 27 to 34 years. The majority of the participants had an experience of participating in self-care (88.7%) and patient care (83.7%) training courses against COVID-19. The overall score of self-care was 55.96 ± 6.97 out of 72 and that of patient care was 26.86± 3.39 out of 32, both of which revealed a favorable level. However, in some questions, the mean score was lower than the optimal level. The lowest mean score among items related to self-care against COVID-19 was allocated to wearing protective clothing (1.77±1.19). Among items related to patient care against COVID-19, the lowest mean score was related to training the patient about hand hygine after touching contaminated equipment (2.83±1.08 out of 4). There was a positive (r=0.491) and significant correlation between self-care and patient care against COVID-19 (p=0.001) based on our findings.

Conclusion: Although the general level of self-care and patient care against COVID-19 was favorable, due to the undesired level of some domains, it seems necessary to implement corrective planning through periodical training and monitoring the performance of the personnel.

The Effect of Intravenous Metoclopramide on Gastric Emptying of Opium-dependent Patients based on Ultrasonographic Criteria; a Case-control Study

Faramarz Mosaffa, Ali Arhami Dolatabadi, Masoomeh Raoufi, Faezeh Golpour, Mahshid Ghasemi, Mohammad Javad Yazdipoor, Elham Memary (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e6

Introduction: Induction of anesthesia for emergency procedures, without prior gastric preparation and incomplete fasting, is associated with the risk of reflux of stomach contents and aspiration. This study aimed to evaluate the effect of intravenous (IV) metoclopramide administration on gastric emptying in opium users, candidate for procedural sedation and analgesia (PSA).

Methods: In the present case-control study, opium-dependent (case) and non-dependent (control) patients in need of PSA were administered with 10 mg IV metoclopramide after undergoing gastric ultrasonography for determination of its area and contents. Then, 30 minutes after the administration of metoclopramide, the area and contents of the stomach were measured again and compared with the measures obtained before the intervention.

Results: 135 patients were evaluated in three groups of 45, including the case, control, and placebo groups. The three groups were similar regarding mean age (p = 0.068), sex (p = 0.067), weight (p = 0.596), height (p = 0.671), body mass index (BMI) (p = 0.877), duration of fasting (p = 0.596), and type of gastric contents (p = 0.124). Mean antral cross-sectional area (CSA) of the study participants in the case, control, and placebo groups before the administration of the drug was 8.49 ± 1.40, 8.31 ± 2.56, and 6.56 ± 1.72 cm2, respectively. Mean gastric area in the case (p < 0.001) and control (p < 0.001) groups had significantly decreased after the intervention. Mean antral gastric grade of gastric contents in the case (p < 0.001) and control (p < 0.001) groups had significantly decreased after the intervention.

Conclusion: It seems that metoclopramide administration in opium users in need of PSA leads to a significant decrease in mean gastric area and increases gastric emptying.

The Effect of L-Citrulline Supplementation on Outcomes of Critically Ill Patients under Mechanical Ventilation; a Double-Blind Randomized Controlled Trial

Mohammadreza Asgary, Sayid Mahdi Mirghazanfari, Ebrahim Hazrati, Vahid Hadi, Mojgan Mehri Ardestani, Faeze bani Yaghoobi, Saeid Hadi (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e11

Introduction: Effective parenteral and enteral amino acid replacement is crucial for critically ill patients with altered amino acid metabolism. This study aimed to assess the effects of l-citrulline supplementation on the clinical and laboratory outcomes in critically patients.

Methods: This was a double-blind placebo-controlled randomized clinical trial. 82 critically ill patients who were expected to receive mechanical ventilation for more than 72 hours were selected. The patients were assigned to either a placebo or an intervention group. The patients in the placebo group received 10 gr of microcrystalline cellulose and the ones in the intervention group were given l-citrulline daily for 7 days.  Serum levels of fasting blood sugar (FBS), lipid profile, hepatic enzymes, serum electrolytes, urea nitrogen, creatinine, and C-reactive protein (CRP) were evaluated before and after the intervention. Duration of invasive ventilation, intensive care unit (ICU) length of stay, ventilator-free days, and 28-day mortality rate were recorded and compared between groups.

Results: Eighty-two patients completed the trial. No statistically significant differences were observed between the two groups in terms of age (p = 0.46), sex (p = 0.49), body mass index (BMI) (p = 0.41), Sequential Organ Failure Assessment (SOFA) Score (p = 0.08), Clinical Pulmonary Infection Score (CPIS) score (p = 0.76), Acute Physiology and Chronic Health Evaluation (APACHE II) score (p = 0.58), risk factors (p = 0.13), ICU stay before randomization (p = 0.32), and reason of admission (p = 0.50) before the intervention. Citrulline group had a notable reduction in FBS (p = 0.04), total cholesterol (TC) (p = 0.02), low density lipoprotein (LDL-C) (p <0.001) and high-sensitivity CRP (hs-CRP) (p <0.001). Also, a significant increase in lactate dehydrogenase (LDH) concentration (p <0.001) was observed in the intervention group at the end of the trial. Total duration of invasive ventilation and the mean SOFA score on 7th day were significantly lower in the citrulline group compared to the control group. Moreover, a significant increase in days alive and ventilator-free days within 28 days after admission was found in the citrulline group at the end of the trial. Also, there were no significant differences between the groups in terms of mortality rate during intervention, serious adverse events, endotracheal intubation, the use of tracheotomy or non-invasive ventilation after extubation, length of ICU stay, ICU-free days at 28 days, and CPIS and APACHE II scores.

For mortality, in the citrulline group, there was two deaths compared to eight deaths in the control group. This resulted in an absolute risk reduction (ARR) of 14.05% (95% CI: 0.39–27.71%) and a number needed to treat (NNT) of 7.1 (95% CI: 3.6–29.5), regarding mortality.

Conclusions: The results of the present study demonstrated the probable positive effects of citrulline supplementation on lipid profile, hs-CRP levels, duration of invasive ventilation, and SOFA score. Also, l-citrulline consumption may increase the probability of survival without mechanical ventilation.

Dizziness Evaluation and Characterisation of Patients with Posterior Circulation Stroke in the Emergency Department; a Case Series Study

Miguel Saro- Buendía, Lidia Torres García, Natalia Jaramillo Angel, Raul Mellidez Acosta, Javier Cabrera Guijo, Catalina Bancalari Díaz, Alfonso García Piñero, Vanesa Pérez Guillén, Miguel Armengot Carceller (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e12

Introduction:  Dizziness is a common scenario in the Emergency Departments (EDs). Among dizziness underlying causes, the posterior circulation stroke is especially relevant due to its mobimortality and concerning misdiagnosis rates. Therefore, we conducted this study to assess dizziness evaluation and baseline characteristics of patients with PS in the ED.

Methods: We conducted a 3-year retrospective observational study on PS cases confirmed by magnetic resonance imaging (MRI). Concretely, we analysed the demographic profile of these patients, the initial PS clinical presentation, and diagnostic workup (with emphasis on dizziness evaluation) performed at the ED.

Results: During the study period, 85 cases were registered. Risk factors for cardiovascular disease were present in 85.5% and previous visits to the ED due to dizziness were recorded in 16.5%. The main clinical presentation was dizziness, concretely as an acute vestibular syndrome (38.8%) with additional neurological signs or symptoms (80%). Evaluation by the otolaryngologist on call was requested in less than 10% of the cases and included the HINTS protocol use with a sensitivity of 100% for central nervous system underlying causality. A brain CT study was always performed with a sensitivity of 27%. However, 96.47% of patients were primarily admitted to the Neurology hospitalization ward and MRI was always performed in a mean time of 3.21 days confirming the diagnosis.

Conclusions: Dizziness is the most frequent symptom of PS. Patients usually present an AVS (associated with additional N-SS or not) and HINTS bedside examination is the most adequate protocol to differentiate a PS from other AVS causes until the diagnostic confirmation via MRI. Interestingly, mainly otolaryngologists seem to use HINTS. However, the use of CT is widespread despite its poor value.

Comparing the Emergency Medicine Residency Programs in Iran and around the World; a Descriptive Study

Mahdi Talebi, Morteza Talebi Doluee, Mohamadali Jafari, Hamid Zamani Moghaddam, Mojtaba Moazzami, Mahdi Foroughian, Hassan Gholami, Hamidreza Reihani (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e13

Introduction: To identify the strengths and weaknesses of emergency medicine residency curriculum in Iran, and to benefit from the experiences of successful universities, comparative studies are crucial. This study compared the components of the national curriculum of emergency medicine in the United States, Canada, the European Union, Australia, and Saudi Arabia with Iran.

Method: Data for this research was collected by searching the websites of different universities and also contacting them for requesting curriculums. The leading countries in emergency medicine and one of the countries in the Middle East region (Saudi Arabia) along with the World Federation of Emergency Medicine were selected as the sample. The model used in this field is a range model that identifies four stages of description, interpretation, proximity, and comparison in comparative studies.

Results: In the curriculum of the United States, Canada, the European Union, Australia, and Saudi Arabia, there were lots of similarities in expressing the general characteristics of the curriculum, mission elements, vision, values, and ​beliefs of the discipline, educational strategy, techniques, expected competencies, rotation programs, and evaluation method, which were also similar to the Iranian curriculum. However, the duration of residency for emergency medicine in Iran is three years, which is shorter than other countries. As expected, the number and duration of rotations are less than other countries. Also, the process of entering into this field is different in Iran and is based on an exam for entrance, while most other countries use self-requested residency program.

Conclusion: Considering the results of comparing the Iranian curriculum with the curriculums of the United States, Canada, the European Union, Australia, and Saudi Arabia, it seems that Iran's program is comprehensive and complete; but, a reappraisal of the course duration and entering options are necessary to eliminate or improve the inadequacies.

Effect of Ticagrelor Compared to Clopidogrel on Short-term Outcomes of COVID-19 Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention; a Randomized Clinical Trial

Reza Arefizadeh, Seyed Hossein Moosavi, Sayied Towfiqie, Seyed Abolfazl Mohsenizadeh, Mehdi Pishgahi (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e14

Introduction: Acute COVID-19 infection is associated with increased adverse clinical outcomes in patients with acute coronary syndromes (ACS). Given that some studies suggested improved pulmonary function with Ticagrelor, this clinical trial aimed to compare the effects of Ticagrelor versus Clopidogrel on the short-term outcomes of these patients.

Methods: In this multicenter clinical trial, 180 COVID-19 patients with ACS who underwent urgent percutaneous coronary intervention (PCI) were randomized to receive Ticagrelor (180mg loading dose followed by 90mg twice daily, n=90) or Clopidogrel (600mg loading dose with 75mg daily, n=90), and then followed for one month after their procedure. The primary composite endpoint was a combination of all-cause mortality, myocardial infarction, and early stent thrombosis within the first month after stent implantation.

Results: After thirty days of follow-up, the primary composite endpoint was non-significantly lower in the Ticagrelor compared to the Clopidogrel group (18.5% vs 23.5% respectively, p = 0.254). Based on the time-to-event analysis, the mean survival rate was 26.8 ±7.7 and 24.7 ±9.9 days, respectively, for the Ticagrelor and the Clopidogrel arms (Log-rank p = 0.275). Secondary endpoints were similar in the two trial arms, except for the mean oxygen saturation, which was higher in the Ticagrelor group (95.28 ±2.68 % vs. 94.15 ± 3.55 %, respectively; p = 0.021).

Conclusion: Among COVID-19 patients with concomitant ACS, who were treated with urgent PCI, the composite outcome of death, myocardial infarction, and early stent thrombosis was not different between Ticagrelor and Clopidogrel groups. However, administration of Ticagrelor was associated with a slight but statistically significant increase in oxygen saturation compared to Clopidogrel, but this difference wasn’t clinically important.

Clinical Risk Factors of Need for Intensive Care Unit Admission of COVID-19 Patients; a Cross-sectional Study

Farshid Sharifi, Mohammad Hossain Mehrolhassani, Milad Ahmadi Gohari , Ali Karamoozian, Yunes Jahani (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e15

Introduction: It could be beneficial to accelerate the hospitalization of patients with the identified clinical risk factors of intensive care unit (ICU) admission, in order to control and reduce COVID-19-related mortality. This study aimed to determine the clinical risk factors associated with ICU hospitalization of COVID-19 patients.

Methods: The current research was a cross-sectional study. The study recruited 7182 patients who had positive PCR tests between February 23, 2020, and September 7, 2021 and were admitted to Afzalipour Hospital in Kerman, Iran, for at least 24 hours. Their demographic characteristics, underlying diseases, and clinical parameters were collected. In order to analyze the relationship between the studied variables and ICU admission, multiple logistic regression model, classification tree, and support vector machine were used. 

Results: It was found that 14.7 percent (1056 patients) of the study participants were admitted to ICU. The patients’ average age was 51.25±21 years, and 52.8% of them were male. In the study, some factors such as decreasing oxygen saturation level (OR=0.954, 95%CI: 0.944-0.964), age (OR=1.007, 95%CI: 1.004-1.011), respiratory distress (OR=1.658, 95%CI: 1.410-1.951), reduced level of consciousness (OR=2.487, 95%CI: 1.721-3.596), hypertension (OR=1.249, 95%CI: 1.042-1.496), chronic pulmonary disease (OR=1.250, 95%CI: 1.006-1.554), heart diseases (OR=1.250, 95%CI: 1.009-1.548), chronic kidney disease (OR=1.515, 95%CI: 1.111-2.066), cancer (OR=1.682, 95%CI: 1.130-2.505), seizures (OR=3.428, 95%CI: 1.615-7.274), and gender (OR=1.179, 95%CI: 1.028-1.352) were found to significantly affect ICU admissions.

Conclusions: As evidenced by the obtained results, blood oxygen saturation level, the patient's age, and their level of consciousness are crucial for ICU admission.

Associated Factors of In-hospital Mortality among Intubated Older Adults in Emergency Department; a Cross-sectional Study

Mohd Idzwan Zakaria, Norhadila Che Manshor, Maw Pin Tan (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e16

Introduction: A decision-making guideline on when to intubate an older person based on predictors of intubation outcome would be extremely beneficial. This study aimed to identify the associated factors that could predict the outcomes of endotracheal intubation among older adults in the Emergency Department (ED).

Methods: In this retrospective cross-sectional study, patients aged ≥65 years intubated at the ED of University of Malaya Medical Centre, Kuala Lumpur, Malaysia, from 2015 to 2019 were studied. The association between age, gender, place of inhabitation, Identification of Seniors at Risk (ISAR) score for frailty, Charlson Comorbidity Index (CCI), Acute Physiology and Chronic Health Evaluation-II (APACHE-II) score, indication for intubation, and diagnosis on admission with in-hospital mortality (primary outcome) and duration of ventilation, and length of stay (secondary outcomes) were evaluated using univariate analysis and Cox’s regression survival analysis.

Results: 889 cases aged 65 years and above were studied (61.5% male). The rate of in-hospital mortality was 71.4%. There was a significant association between age (p < 0.001), nursing home residency (p = 0.008), CCI≥ 5 (p = 0.001), APACHE-II (p < 0.001), pre-intubation Glasgow Coma Scale (GCS) (p < 0.001), cardiac arrest as indication of intubation (p < 0.001), diagnosis on admission (p < 0.001), length of stay (p < 0.001), and length of ventilation (p = 0.003) and in-hospital mortality.  Age ≥ 85 years (HR= 1.270; 95%CI=1.074 to 1.502) and 75 to 84 years (HR=1.642; 95%CI=1.167 to 2.076), cardiac arrest as indication of intubation (HR: 1.882; 95% CI: 1.554 – 2.279), and APACHE-II scores 25 – 34 (HR: 1.423; 95% CI: 1.171 - 1.730) and ≥ 35 (HR: 1.789; 95%CI: 1.418 - 2.256) were amongst the independent predictive factors of in-hospital mortality. 

Conclusion: Nearly three out of four individuals aged ≥65 years intubated at the ED died during the same admission. Older age, cardiac arrest as indication of intubation, and APACHE-II score were independent predictors of in-hospital mortality.

Long-term Complications of COVID-19 in Nursing Staff; a Retrospective Longitudinal Study

Koorosh Etemad, Hossein Hatami, Mahnaz Nikpeyma, Forough Mowla, Fatemeh Fallah Atatalab (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e17

Introduction: Although the lungs are the main target of coronavirus disease (COVID-19), infection is also associated with a high rate of extra-pulmonary complications. This study aimed to evaluate the one-year incidence of long-term COVID-19 complications among the nursing staff.

Methods: This study is a retrospective longitudinal study. All nursing staff working in public hospitals affiliated with Shahid Beheshti University of Medical Sciences who had been affected with COVID-19 were included in the study via convenience sampling method. The patients were recruited from 20th February 2020 to 20th March 2021.

Result: 1762 nursing staff with a mean age of 35.08 ± 8.02 (Range: 22-66) years were studied (73.5% female). The results showed that among those who reported at least one type of complication, the duration of complications was significantly longer than 1 week and the median was 8 weeks.

The findings demonstrated that complications occurred in 65% of infected females. For men, this rate was 62.3%. Generalized pain, anxiety disorders, and skin complications were among the complications that were significantly more common in women than in men. Additionally, the incidence of anosmia, ageusia, anxiety disorders, and skin complications was significantly higher in younger people than in older people.  The comparison of complications revealed that nurses were significantly more likely than other occupations to experience respiratory complications, anosmia and ageusia, generalized pain, and skin complications and that outpatients experienced significantly more complications than hospitalized patients.

Conclusion: The one-year cumulative incidence of long-term complications in nursing staff with COVID-19 was 64.3%. The most common complications were respiratory complications, generalized pain, anosmia, and ageusia, respectively.

Pattern of Neurological Disorders among Patients Evaluated in the Emergency Department; Cross–Sectional Study

Mohamed Sheikh Hassan, Nor Osman Sidow, Alper GÖKGÜL, Bakar Ali Adam, Mohamed Farah Osman, Hussein Hassan Mohamed, Ismail Gedi Ibrahim, Ishak Ahmed Abdi (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e20

Introduction: Neurologic disorders are common reasons for emergency consultations. Most neurologic disorders seen in the emergency department (ED) are life-threatening and require urgent treatment. The goal of this study is to investigate the pattern of neurological disorders among patients evaluated in the ED.

Methods: This is a cross-sectional study conducted in the ED of Mogadishu Somali Turkish Training and Research Hospital, from July 2021 to February 2022.  The clinical and epidemiological characteristics of adult patients with neurologic manifestations in the ED were evaluated. Age, gender, distribution of neurological disease manifestations, neurological examination findings, and neurological diagnoses made by consultant neurologists were assessed.

Results: During the study period, 321 patients were assessed (3.7% of all ED admissions). The majority of the patients in the study were above 50 years of age (62.6% male). Hypertension was the most common comorbidity among these patients with 122 (38%) cases, followed by diabetes mellitus with 65 (20.2%), and heart diseases with 26 (8.1%) cases. The main reasons for neurology consultations were altered mental status with 141 (44%) cases, motor weakness with 102 (31.8%), seizures with 33 (10%), headache with 17 (5.3%), and vertigo with 9 (2.8%) cases. 196 (61%) had hemiplegia, 60 (18.7%) had consciousness impairment, and 38 (11.8%) had normal neurological examination. The most frequent neurological diagnoses were ischemic strokes with 125 (39%) cases, hemorrhagic strokes with 65 (20.2%), epileptic seizures with 28 (8.7%), and metabolic encephalopathies with 13 (4%) cases. The median duration of the neurology consultations was 20 minutes. 251 (78%) of the patients were admitted to the hospital, while 70 (22%) were discharged from the emergency department. After neurology consultation, the neurology department made the most admissions with 226 (90%) cases, while 25 (10%) were admitted by other departments. Of those admitted, 186 (74.2%) were admitted to the neurology ward, and 65 (25.8%) were admitted to the intensive care unit.

Conclusion: In our study, neurologic emergencies accounted for 3.7% of all emergency admissions. Stroke, epileptic seizures, cerebral venous thrombosis, encephalopathies, and acute spinal cord diseases were the most common neurological disorders.  The admission rate was very high following neurologic assessment by neurologists.

Effect of Out-Of-Hour Admission on Fluid Treatment of Emergency Department Patients with Suspected Infection; a Multicenter Post-Hoc Analysis

Marie Kristine Jessen, Anna Drescher Petersen, Hans Kirkegaard (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e21

Introduction: Sepsis is a life-threatening and common cause of Emergency department (ED) referrals. Out-of-hour staffing is limited in ED, which may potentially affect fluid administration. This study aimed to investigate fluid volume variation in out-of-hour vs. routine-hour admissions.

Methods: The present study is a post-hoc analysis of a multicentre, prospective, observational study investigating fluid administration in ED patients with suspected infection, from Jan 20th - March 2nd, 2020. Patient groups were “routine-hours” (RH): weekdays 07:00-18:59 or “out-of-hours” (OOH): weekdays 19:00-06:59 or Friday 19:00-Monday 06:59. Primary outcome was 24-hour total fluid volumes (oral + intravenous (IV)). Secondary outcomes were total fluids 0-6 hours, oral fluids 0-6 and 0-24 hours, and IV fluids 0-6 and 0-24 hours. Linear regression adjusted for site and illness severity was used.

Results: 734 patients had suspected infection; 449 were admitted during RH and 287 during OOH. Mean (95% CI) total 24-hour fluid volumes were equal in simple infection and sepsis regardless of admission time: Simple infection RH: 3640 (3410 - 3871) ml and OOH: 3681 (3451 - 3913) ml. Sepsis RH: 3671 (3443;3898) ml and OOH: 3896 (3542;4250) ml. Oral fluids 0-6h were reduced in simple infection and sepsis among OOH vs. RH. Sepsis patients received more 0-6-hour IV fluid when admitted OOH vs. RH. There were no associations between admission time and 0-24-hour oral or IV volumes in simple infection or sepsis. 

Conclusion: Admission time did not have an association with 24-hour total fluid volumes. Sepsis patients admitted during OOH received more 0-6-hour IV fluids than RH patients, and simple infection and sepsis patients received less oral fluid in 0-6 hours if admitted during OOH vs. RH.

Introduction: One type of the developed COVID-19 vaccines that received emergency permission and was approved by the food and drug administration (FDA) is the mRNA-based vaccine. The aim of this study is to gather information on the Jordanian population's experience with the vaccine's side effects.

Methods: The study objectives were addressed through a cross-sectional study, which collected information regarding the short-term side effects experienced by the vaccinated individuals within one month following the injection of an mRNA-based COVID-19 vaccine. Data collection was carried out in August 2021. Participants were invited to take part in a self-administered web-based survey created using Google Forms.

Results: Among the study’s participants (n= 533), about 56% experienced side effects after the first dose of the mRNA-based COVID-19 vaccine. The most commonly reported side effects after the first dose were sore arm at the injection site (91.6%), and fatigue (83.06%). The female gender was significantly associated with experiencing fatigue, discomfort, chills, and hair loss. Being over 30 years old was significantly associated with experiencing cough. Being a smoker was significantly associated with experiencing shortness of breath and gastrointestinal symptoms.

Conclusion: The mRNA-based COVID-19 vaccine side effects were common, yet, mild, local, and self-limited. The local pain at the injection site was the most commonly reported side effect. Hopefully, the study's findings will aid in lowering resistance to vaccination.

Two-Stage Clinical Model for Screening the Suspected Cases of Acute Ischemic Stroke in Need of Imaging in Emergency Department; a Cross-sectional Study

Somayeh Karimi, Lorraine Martins Dutra e Oliva, Hosein Rafiemanesh, Melissa Mendez Capitaine, Sarah Jabre, Alireza Baratloo (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e23

Introduction: Just as failure to diagnose an acute ischemic stroke (AIS) in a timely manner affects the patient's outcome; an inaccurate and misplaced impression of the AIS diagnosis is not without its drawbacks. Here, we introduce a two-stage clinical tool to aid in the screening of AIS cases in need of imaging in the emergency department (ED).

Methods: This was a multicenter cross-sectional study, in which suspected AIS patients who underwent a brain magnetic resonance imaging (MRI) were included. The 18 variables from nine existing AIS screening tools were extracted and a two-stage screening tool was developed based on expert opinion (stage-one or rule in stage) and multivariate logistic regression analysis (stage-two or rule out stage). Then, the screening performance characteristics of the two-stage mode was evaluated.

Results: Data from 803 patients with suspected AIS were analyzed. Among them, 57.4 % were male, and their overall mean age was 66.9 ± 13.9 years. There were 561 (69.9%) cases with a final confirmed diagnosis of AIS. The total sensitivity and specificity of the two-stage screening model were 99.11% (95% CI: 98.33 to 99.89) and 35.95% (95% CI: 29.90 to 42.0), respectively. Also, the positive and negative predictive values of two-stage screening model were 78.20% (95% CI: 75.17 to 81.24) and 94.57% (95% CI: 89.93 to 81.24), respectively. The area under the receiver operating characteristic (ROC) curve of the two-stage screening model for AIS was 67.53% (95% CI: 64.48 to 70.58). Overall, using the two-stage screening model presented in this study, more than 11% of suspected AIS patients were not referred for MRI, and the error of this model is about 5%.

Conclusion: Here, we proposed a 2-step model for approaching suspected AIS patients in ED for an attempt to safely exclude patients with the least probability of having an AIS as a diagnosis. However, further surveys are required to assess its accuracy and it may even need some modifications.

Association Between Neutrophil Density and Survival in Trauma Patients Admitted to the Intensive Care Unit; a Retrospective Cohort Study

Mohebat Vali, Shahram Paydar , Mozhgan Seif , Maryam Hosseini, Pardis Basiri, Golnar Sabetian, Haleh Ghaem (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e29

Introduction: Altered immune responses, in particular neutrophil changes, are perceived to play a key role in immune responses to trauma. This study aimed to evaluate the association of neutrophil changes with patients’ survival in severe multiple trauma cases.

Methods: The current retrospective cohort study was conducted using data from patients admitted in the intensive care unit (ICU) of a trauma center in Shiraz, Iran, between 2016 and 2021. Patients were divided into three groups (i.e., normal, neutropenia, and neutrophilia) based on neutrophil count at the time of ICU admission, and the association of neutrophil count with in-hospital mortality was analyzed.

Results: 2176 patients with the mean age of 37.90 ± 18.57 years were evaluated (84.04% male). The median trauma severity based on injury severity score (ISS) in this series was 9 (4 -17). Patients were divided in to three groups of neutrophilia (n = 1805), normal (n = 357), and neutropenia (n = 14) There were not any significant differences between groups regarding age distribution (p = 0.634), gender (p = 0.544), and trauma severity (p = 0.197). The median survival times for the normal, neutropenia, and neutrophilia groups were 49 (IQR: 33 -47) days, 51 (IQR: 8- 51) days, and 38 (IQR: 26 - 52) days, respectively (p = 0.346). The log-rank test showed a statistically significant difference between the three groups adjustment for ISS (p ≤ 0.001). For each unit increase in ISS, the hazard ratio increased by 2%. In ISS 9-17, the hazard ratio increased by 11% compared to ISS<4. Also, in ISS>17, the hazard ratio increased by 76% compared to ISS<4 in ICU-hospitalized patients.

Conclusions: In general, the findings of the present study showed that the survival rate of patients in the normal group after ISS adjustment was higher than the other two groups. Also, the Cox model showed that the mortality risk ratio in the neutropenia group was 15 times higher than the normal group.

Ottawa Risk Scale in Predicting the Outcome of Chorionic Obstructive Pulmonary Disease Exacerbation in Emergency Department; a Diagnostic Accuracy Study

Mostafa Alavi-Moghaddam, Hossein Partovinezhad, Shayan Dasdar, Maryam Farjad (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e32

Introduction: The disposition decision is a great challenge for clinicians in managing patients with chronic obstructive pulmonary disease (COPD) exacerbation. This study aimed to evaluate the accuracy of Ottawa COPD Risk Scale (OCRS) in predicting the short-term adverse events in the mentioned patients.

Methods:  This prospective diagnostic accuracy study was conducted on COPD exacerbation cases who were referred to the emergency department (ED). Patients were followed up for 30 consecutive days for adverse events including the need for intubation, non-invasive ventilation, myocardial infarction, readmission, and death from any cause, and finally the accuracy of OCRS in predicting the outcome was evaluated.

Results: 362 patients with the mean age of 65.55 ± 10.65 (6- 95) years were evaluated (58.0% male). Among the patients, 164 (45.3%) cases were discharged from ED, and 198 (54.7%) were admitted to the hospital. 136 (37.6%) cases experienced at least one of the studied short-term adverse events. The mean OCSD score of this series was 1.96 ± 2.39 (0 – 10). The area under the curve of OCRS in predicting the outcome of COPD patients was 0.814 (95%CI: 0.766 – 0.862). The best cut-off point of the scale in predicting the outcome was 1.5. The sensitivity and specificity of the scale were 75.75% (95%CI: 69.6% – 81.42%) and 89.63% (95%CI: 83.67% – 93.66%), respectively. By employing this threshold, 48 (13.25%) cases would have unnecessary hospitalization, and 17 (0.04%) would be discharged incorrectly.

Conclusion: The OCRS has acceptable level of prediction accuracy in predicting the short-term adverse event of COPD patients. The use of this scoring in the routine practice of ED clinicians can lead to a reduction in unnecessary admissions and unsafe discharge for these patients.

Sustained Return of Spontaneous Circulation Following Out-of-Hospital Cardiac Arrest; Developing a Predictive Model Based on Multivariate Analysis

Thongpitak Huabbangyang, Agasak Silakoon, Pramote Papukdee, Rossakorn Klaiangthong, Chaleamlap Thongpean, Wannakorn Pralomcharoensuk, Weerawan Khaokaen, Sunisa Bumrongchai, Ratree Chaisorn, Chomkamol Saumok (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e33

Introduction: Identifying the predictive factors of sustained return of spontaneous circulation (ROSC) following out-of-hospital cardiac arrest (OHCA) will be helpful in management of these patients. This study aimed to develop a predictive model in this regard.

Methods: In a retrospective observational study, data of adult patients with OHCA, were collected from Vajira emergency medical services patient care report. Multiple logistic regression analysis with a regression coefficient was used to develop a predictive score for a sustained ROSC at the scene. Area under the receiver operating characteristic (ROC) curve (AUC) was used to validate the accuracy of the predictive score for a sustained ROSC.

Results: Independent factors associated with a sustained ROSC included cardiopulmonary resuscitation (CPR) duration < 30 min (adjusted odds ratio (AOR)= 5.05, 95% confidence interval (CI): 3.34–7.65; p < 0.001); advanced airway management with an endotracheal tube (AOR= 3.06, 95% CI: 1.77–5.31; p < 0.001); advanced airway management with laryngeal mask airway (AOR= 3.42, 95% CI: 1.02–11.46; p = 0.046); defibrillation (AOR = 2.05, 95% CI: 1.31–3.2; p = 0.002); Capillary blood glucose (CBG) level < 150 mg% (AOR= 1.95, 95% CI: 1.05–3.65; p = 0.035); CBG at least 150 mg% (AOR= 2.87, 95% CI: 1.56–5.29; p = 0.001); pupil reflex (AOR = 2.96, 95% CI: 1.1–7.96; p = 0.032); and response time at most 8 min (AOR= 1.66, 95% CI: 1.07–2.57; p = 0.023). These were developed into the pupil reflex, response time, advanced airway management, defibrillation, CBG, and CPR duration (PRAD-CCPR) score. The most accurate cutoff point of score using Youden’s index was ≥ 6 with AUC of 0.759 (95% CI: 0.715–0.802; p < 0.001), sensitivity of 62.0% (95% CI: 51.2–71.9%), specificity of 75.7% (95% CI: 69.4–81.2%), positive predictive value of 51.8% (95% CI: 40.9–62.3%), and negative predictive value of 79.5% (95% CI: 73.5–84.6%).

Conclusion: An optimal PRAD-CCPR score of ≥ 6 provides an acceptable accuracy of 0.759 with sensitivity of 62.0% and specificity of 75.7% in prediction of sustained ROSC following OHCA. This predictive score might help CPR commanders to prognosticate the outcome of patients with OHCA at the scene.

Modified Shock Index as a Predictor of Admission and In-hospital Mortality in Emergency Departments; an Analysis of a US National Database

Bachar Hamade, Jamil D Bayram, Yu-Hsiang Hsieh, Basem Khishfe, Nour Al Jalbout (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e34

Introduction: The modified shock index (MSI) is the ratio of heart rate to mean arterial pressure. It is used as a predictive and prognostic marker in a variety of disease states. This study aimed to derive the optimal MSI cut-off that is associated with increased likelihood (likelihood ratio, LR) of admission and in-hospital mortality in patients presenting to emergency department (ED).

Methods: We retrospectively reviewed data from the National Hospital Ambulatory Medical Care Survey between 2005 and 2010. Adults>18 years of age were included regardless of chief complaint. Basic patient demographics, initial vital signs, and outcomes were recorded for each patient. Then the optimal MSI cut-off for prediction of admission and in-hospital mortality in ED was calculated. LR ≥ 5 was considered clinically significant.

Results: 567,994,402 distinct weighted adult ED patient visits were included in the analysis. 15.7% and 2.4% resulted in admissions and in-hospital mortality, respectively. MSI > 1.7 was associated with a moderate increase in the likelihood of both admission (Positive LR (+LR) = 6.29) and in-hospital mortality (+LR = 5.12). +LR for hospital admission at MSI >1.7 was higher for men (7.13; 95% CI 7.11-7.15) compared to women (5.49; 95% CI 5.47-5.50) and for non-white (7.92; 95% CI 7.88-7.95) compared to white patients (5.85; 95% CI 5.84-5.86).  For MSI <0.7, the +LRs were not clinically significant for admission (+LR = 1.07) or in-hospital mortality (LR = 0.75).

Conclusion: In this largest retrospective study, to date, on MSI in the undifferentiated ED population, we demonstrated that an MSI >1.7 on presentation is predictive of admission and in-hospital mortality. The use of MSI could help guide accurate acuity designation, resource allocation, and disposition.

Dental Students' Perceptions Regarding Bioterrorism; a Cross-Sectional Study

Lina Bahanan, Maha Alsharif, Omar Al Qhtani, Ahmad Al Juhani, Meyassara Samman (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e40

Introduction: During the COVID-19 outbreak, dental professionals have demonstrated their importance in combating mass casualty incidents. This study aimed to understand dental students’ perceptions of their potential roles in a bioterrorism attack. 

Methods: This cross-sectional study used a self-administered anonymous questionnaire, which was sent to all dental students and interns at King Abdulaziz University, Saudi Arabia. Bivariate and multiple linear regression analyses were conducted to assess dental students’ willingness to provide care during a bioterrorism attack, knowledge regarding bioterrorism and total number of roles a dentist should play during an attack.

Results: This study included 472 dental students and interns. The mean knowledge score regarding bioterrorism was 3.3 ± 1.9 out of 5. A large majority of the respondents (83.8%) were willing to provide care during a bioterrorism attack. Students with a cumulative grade point average (GPA) of 4.5–5 were more likely to indicate that a dental professional should take on more roles during a bioterrorism attack than those with a GPA of 2.5–2.99. Fourth- and fifth-year dental students had lower knowledge scores regarding bioterrorism than dental interns (B: -0.71; SE: 0.30; 95% CI: -1.3–-0.1 and B: -0.68; SE: 0.30; 95% CI: -1.3– -0.1, respectively).

Conclusion: Despite the fact that dental curricula do not cover topics related to bioterrorism, most students would be willing to provide care under bioterrorism conditions. There is wide agreement among the students regarding the need to add bioterrorism-related educations to dental curricula.

Using Sodium Bicarbonate During Prolonged Cardiopulmonary Resuscitation in Prehospital Setting; a Retrospective Cross-sectional Study

Thongpitak Huabbangyang, Chunlanee Sangketchon, Gotchagorn Noimo, Korawee Pinthong, Ketvipa Saungun, Kaiwit Bunta, Chomkamol Saumok (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e41

Introduction: Although the 2020 American Heart Association (AHA) guidelines recommend that sodium bicarbonate (SB) be avoided during routine cardiopulmonary resuscitation (CPR) a limited number of studies have examined the effects of SB injection during prolonged CPR (>15 min) in prehospital setting. The present study aimed to examine the effects of prehospital SB use during prolonged CPR on patients’ outcome.

Methods: In this retrospective cross-sectional study adult patients aged >18 years who experienced a non-traumatic, out-of-hospital cardiac arrest (OHCA) were compared regarding three outcomes, namely return of spontaneous circulation (ROSC), ROSC > 20 minute, and survival to discharge, based on receiving or not-receiving SB during CPR.

Results: 330 patients were divided into two equal groups of 165. The two groups had similar conditions regarding gender distribution (p = 0.729); mean age (p = 0.741); underlying diseases (p = 0.027); etiology of arrest (p = 0.135); the initial rhythm (p = 0.324); receiving normal saline solution (p = 1.000), epinephrine (p = 0.848), and atropine during CPR (p = 0.054); and using defibrillation (p = 0.324). Those who received SB had 0.80 times greater likelihood for sustained ROSC (adjusted odds ratio (OR) = 0.80, 95% CI: 0.47–1.37, p = 0.415), 0.93 times greater likelihood for ROSC at the scene (adjusted OR = 0.93, 95% CI: 0.55–1.59, p = 0.798), and 0.34 times greater likelihood for survival to discharge (adjusted OR = 0.34, 95% CI: 0.10–1.17, p = 0.087).

Conclusions: The present study demonstrated that prehospital SB use by EMS during prolonged CPR did not improve ROSC rate at the scene, sustained ROSC, and survival to discharge.

The Value of Complete Blood Count Parameters in Predicting Complicated Acute Appendicitis; a Prognostic Accuracy Study

Natchanok Mekrugsakit, Thawatchai Tullavardhana (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e42

Introduction: Low accuracy of clinical variables can result in delayed diagnosis and increase the incidence of complicated appendicitis in some cases. This study aimed to determine the value of simple complete blood count (CBC) biomarkers in predicting complicated appendicitis.

Methods: This is a single-center retrospective cross-sectional study, which was conducted on cases referred to emergency department following acute appendicitis who underwent appendectomy, to evaluate the accuracy of some cell blood count variables (white blood cell count (WBC), neutrophil percent, neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), mean platelet volume (MPV)) in predicting complicated cases (gangrenous and ruptured appendicitis).

Results: There were 252 (68.3%) patients in the uncomplicated appendicitis group and 117 (31.7%) patients in the complicated appendicitis group. The mean age of patients was 34.1 ± 1.09 (Range: 18 -79) years (55.3% male). There were no differences between groups regarding the mean age (p = 0.053), gender distribution (p=0.07), Alvarado score (p = 0.055), platelet count (p =0.204), PLR (p = 0.115), and MPV (p = 0.205). The complicated appendicitis cases had longer onset of symptoms (p <0.001), higher WBC count (p = 0.011), higher neutrophil count (p < 0.001), and higher NLR (p < 0.001).

Neutrophil count (area under the curve (AUC) = 0.61, 95% confidence interval (CI) = 0.56-0.66; p = 0.001) and NLR (AUC = 0.65, 95% CI = 0.60-0.69; p = 0.001) had higher level of accuracy in this regard. In contrast, the area under the curve of WBC count (AUC = 0.57, 95% CI = 0.52-0.63; p = 0.22), platelet count (AUC = 0.44, 95% CI = 0.38-0.49; p = 0.049), PLR (AUC = 0.57, 95% CI = 0.52-0.62; p = 0.026), and MPV (AUC = 0.54, 95% CI = 0.49-0.60; p = 0.193) showed low accuracy in predicting complicated acute appendicitis.

Conclusion: Based on the findings of present study it seems that WBC, neutrophil percent, NLR, PLR, and MPV have failed to poor accuracy in predicting cases with complicated appendicitis in emergency department.

The Effects of 3-Month Rosuvastatin Adjuvant Therapy on Post Thrombotic Syndrome following Deep Vein Thrombosis; a Randomized Clinical Trial

Mehdi Pishgahi, Shirin Ghane Fard, Rahil Lak Tabriz, Kimia Karimi Toudeshki, Zahra Talebi (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e43

Introduction: Statins are known to have anticoagulation and anti-inflammatory effects. This study aimed to investigate the effect of Rosuvastatin in reduction of post thrombotic syndrome (PTS) following deep vein thrombosis (DVT).

Methods: In this randomized clinical trial, patients who were diagnosed with DVT of lower extremity were randomly assigned to 4 treatment groups: group 1: Warfarin, group 2: Warfarin + Rosuvastatin, group 3: Rivaroxaban, and group 4: Rivaroxaban + Rosuvastatin. The treatments were followed for 3 months and prevalence of PTS (as primary outcome), as well as the changes in serum levels of D-dimer and C reactive protein (CRP), and the extent of thrombosis before and after the intervention (as secondary outcomes) were compared between groups.

Results: 182 patients with the mean age of 55.22 ± 4.1 years finished the trial period (51.64% male). There was no significant difference between the groups regarding the baseline characteristics. Based on the Brandjes score, 31 (17.03%) patients had PTS at the end of the study. The occurrence of PTS was significantly lower in the groups taking statins (p<0.0001). Although the change in the mean difference of legs circumference before and after intervention, were significant in all groups (p < 0.05), the differences was more prominent in groups 2 and 4 (p < 0.0001). After 3 months of taking medication, decrease of CRP was more prominent in the statin groups (p = 0.001), and most cases with normal CRP were in statin groups. Among the patients with the serum D-dimer level above 10000 ng/mL, patients in the statin groups experienced significantly more reduction in D-dimer levels than the other groups (p<0.001).

Conclusion: Rosuvastatin administration in combination with rivaroxaban or warfarin significantly reduces the level of inflammatory factors including CRP and D-dimer, compared to patients receiving anticoagulants alone. Rosuvastatin administration can significantly reduce the incidence of PTS and cause a difference in the size of the lower limbs within 3 months.

Comparing the Efficacy of Long Spinal Board, Sked Stretcher, and Vacuum Mattress in Cervical Spine Immobilization; a Method-Oriented Experimental Study

Wijittra Liengswangwong, Natcha Lertviboonluk, Chaiyaporn Yuksen, Thanakorn Laksanamapune, Weerawat Limroongreungrat, Atipong Mongkolpichayaruk, Kittichai Tharawadeepimuk, Parunchaya Jamkrajang , Prayoot Sook-Oum, Sorawich watcharakitpaisan (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e43

Introduction: Inadequate spinal motion restriction in patients suffering from spinal injuries could lead to further neurological damage, ultimately worsening their prognosis. This study aimed to investigate the efficacy of long spinal boards (LSB), ske stretcher, and vacuum mattress for cervical spine immobilization during transportation of patients  by measuring the angular motion of the cervical spine following lifting, transferring, and tilting. Methods: We conducted an experimental study using a box of three randomizations and crossover designs without a washout period effect for the long spinal board, sked stretcher, and vacuum mattress. We concealed the randomization with sequentially numbered, opaque, sealed envelopes (SNOSE). Kinematic data were collected using eight optoelectronic cameras at 200 Hz (BTS Bioengineering, Milan, Italy) in triangular planes (lateral bending, flexion-extension, and axial rotation) while performing all three motions (static lift-hold, transfer, and 90° tilt).

Results: 12 cases (7 males and 5 females) with the mean age of 20 ± 3.03 (range: 18-28) years were studied. The three highest angular motions were observed in the axial rotation plane during patient’s tilting under immobilization on all devices (Vacuum mattress having the highest value of 99.01±8.93, followed by the LSB at 89.89±34.35 and the sked stretcher at 86.30±7.73 degrees). During patient lifting, a higher angular motion was observed with vacuum mattress immobilization in flexion extension (Coefficient = 4.45; 95%CI: 0.46 – 8.45; p =0.029) and axial rotation (Coefficient = 3.70; 95%CI: 0.58 – 6.81; p =0.020) planes. During patient transfer, a higher angular motion was observed with sked stretcher in the flexion-extension plane (Coefficient = 2.98; 95%CI: 0.11 – 5.84; p = 0.042). During patient tilting to 90 degrees, a higher angular motion was observed with vacuum mattress immobilization in lateral bending (Coefficient = -4.08; 95%CI: -7.68 - -0.48; p = 0.026) for the vacuum mattress.

Conclusion: Based on the finding of the present study, patients on the vacuum mattress experience significantly higher angular motion in flexion extension and axial rotation during lifting, as well as lateral bending during 90-degree tilting. In addition, patients on the sked stretcher showed significantly higher angular motion in flexion-extension during the transferring. However, the predictive margins for immobilization across all devices did not demonstrate clinically significant differences among the three immobilization devices.

Comparing Two Naloxone Tapering Methods in Management of Methadone Intoxication; a Quasi-experimental Study

Mohammad Javad Zarei, Maral Ramezani, Zahra Sahraie, Shahin Shadnia, Peyman Erfan Talab Evini, Babak Mostafazadeh, Mitra Rahimi (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e46

Introduction: Even though naloxone is the main treatment for methadone poisoning treatment there are controversies about the proper method of its tapering. This study aimed to compare two methods in this regard.

Method: This study was a prospective, single-blind pilot quasi-experimental study on non-addicted adult patients poisoned with methadone. Patients were randomly divided into 2 groups. In one group, after stabilization of respiratory conditions and consciousness, naloxone was tapered using the half-life of methadone and in the other group, naloxone was tapered using the half-life of naloxone. Recurrence of symptoms and changes in venous blood gas parameters were compared between groups as outcome.

Results: 52 patients were included (51.92% female). 31 cases entered Group A (tapering based on methadone’s half-life) and 21 cases entered Group B (tapering based on naloxone’s half-life). The two groups were similar regarding mean age (p = 0.575), gender distribution (p = 0.535), the cause of methadone use (p = 0.599), previous medical history (p = 0.529), previous methadone use (p = 0.654), drug use history (p = 0.444), and vital signs on arrival to emergency department (p = 0.054). The cases of re-decreasing consciousness during tapering (52.38% vs. 25.81%; p = 0.049) and after discontinuation of naloxone (72.73% vs. 37.50%; p = 0.050) were higher in the tapering based on naloxone half-life group. The relative risk reduction (RRR) for naloxone half-life group was -1.03 and for methadone half-life group was 0.51. The absolute risk reduction (ARR) was 0.27 (95% confidence interval (CI) = 0.01-0.53) and the number needed to treat (NNT) was 3.7 (95% CI= 1.87- 150.53). There was not any statistically significant difference between groups regarding pH, HCO3, and PCO2 changes during tapering and after naloxone discontinuation (p > 0.05). However, repeated measures analysis of variance (ANOVA), showed that in the tapering based on methadone’s half-life group, the number of changes and stability in the normal range were better (p < 0.001).

Conclusion: It seems that, by tapering naloxone based on methadone’s half-life, not only blood acid-base disorders are treated, but they also remain stable after discontinuation and the possibility of symptom recurrence is reduced.

Review Article

NEXUS vs. Canadian C-Spine Rule (CCR) in Predicting Cervical Spine Injuries; a Systematic Review and Meta-analysis

Alireza Baratloo, Koohyar Ahmadzadeh, Mohammad Mehdi Forouzanfar, Mahmoud Yousefifard, Mehri Farhang Ranjbar, Behrooz Hashemi, Seyed Hadi Aghili (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e66

Introduction: Clinical decision tools have been shown to reduce imaging rates for clearance of suspected cervical spine injury (CSI). This review provides more comprehensive evidence on the diagnostic capabilities of National Emergency X-Radiography Utilization Study (NEXUS) and Canadian C-spine rule (CCR) in this regard.

Method: A systematic review of the current literature was performed on studies published until Jan 26th, 2023, in databases of Medline, Scopus, Web of Science, and Embase, investigating the performance of NEXUS and CCR in blunt trauma patients. QUADAS-2 and GRADE guidelines were used to assess the quality and certainty of evidence. All analyses were performed using the STATA 14.0 statistical analysis software.

Results: 35 articles comprising 70000 patients for NEXUS and 33000 patients for CCR were included in this review. NEXUS and CCR were evaluated to have a sensitivity of 0.94 (95% confidence interval (CI): 0.88 to 0.98) and 1.00 (95% CI: 0.98 to 1.00) in the detection of any CSI and 0.95 (95% CI: 0.89 to 0.98) and 1.00 (95% CI: 0.95 to 1.00) in the detection of clinically important CSI. The area under the curve (AUC) of NEXUS and CCR was 0.85 and 0.97 for any CSI and 0.78 (95% CI: 0.74 to 0.81) and 0.94 (95% CI: 0.91 to 0.96) for clinically important CSI.

Conclusion: Our study demonstrates that both NEXUS and CCR can be used in ruling out patients with low risk of CSI, and CCR was shown to have superior performance. Even though these tools have low specificity, their application can still greatly reduce the number of radiographic imaging performed in emergency departments. 

Diagnostic Accuracy of Ultrasonography for Identification of Elbow Fractures in Children; a Systematic Review and Meta-analysis

Seyed Mehdi Hosseini Khameneh, Reza Amani-Beni, Seyed-Amirabbas Ahadiat, Mohammad Saeed Kahrizi, Sina Jafari, Seyedehatefe Seyedinnavade, Amir Masood Rafie Manzelat, Noushin Mashatan, Dorsa Beheshtiparvar, Atousa Moghadam Fard, Hamed Lotfi, Hossein Arhami, Reza Barati, Raziyeh Hasanvand, Shima Boorboor, Elaheh Khodaei, Dorsa Dadashzadehasl, Fatemeh Zamani, Roya Khorram, Maryam Ebrahimpour, Zeynab Abdollahi, Mohammadreza Shabani, Nariman Latifi, Reza Vafadar, Sepideh Shah Hosseini, Mehran Khodashenas, Seyyed Morteza Kazemi, Reza Minaei Noshahr, Hani Ghayyem, Alireza Farahani, Diba Saeidi, Sajedeh Jadidi, Babak Goodarzy, Mehrdad Farrokhi (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e62

Introduction: In spite of the results of previous studies regarding the benefits of ultrasonography for diagnosis of elbow fractures in children, the exact accuracy of this imaging modality is still under debate. Therefore, in this diagnostic systematic review and meta-analysis, we aimed to investigate the accuracy of ultrasonography in this regard.

Methods: Two independent reviewers performed systematic search in Web of Science, Embase, PubMed, Cochrane, and Scopus for studies published from inception of these databases to May 2023. Quality assessment of the included studies was performed using Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2). Meta-Disc software version 1.4 and Stata statistical software package version 17.0 were used for statistical analysis.

Results: A total of 648 studies with 1000 patients were included in the meta-analysis. The pooled sensitivity and specificity were 0.95 (95% CI: 0.93-0.97) and 0.87 (95% CI: 0.84-0.90), respectively. Pooled positive likelihood ratio (PLR) was 6.71 (95% CI: 3.86-11.67), negative likelihood ratio (NLR) was 0.09 (95% CI: 0.03-0.22), and pooled diagnostic odds ratio (DOR) of ultrasonography in detection of elbow fracture in children was 89.85 (95% CI: 31.56-255.8). The area under the summary receiver operating characteristic (ROC) curve for accuracy of ultrasonography in this regard was 0.93. Egger's and Begg's analyses showed that there is no significant publication bias (P=0.11 and P=0.29, respectively).

Conclusion: Our meta-analysis revealed that ultrasonography is a relatively promising diagnostic imaging modality for identification of elbow fractures in children. However, clinicians employing ultrasonography for diagnosis of elbow fractures should be aware that studies included in this meta-analysis had limitations regarding methodological quality and are subject to risk of bias. Future high-quality studies with standardization of ultrasonography examination protocol are required to thoroughly validate ultrasonography for elbow fractures.

Introduction: A range of screening tools has been developed to assist emergency healthcare providers in rapidly and accurately diagnosing strokes. In this study, we investigated the diagnostic value of the Recognition of Stroke in the Emergency Room (ROSIER) scale in identifying individuals with stroke and transient ischemic attack (TIA).

Methods: We conducted a systematic search across online databases of PubMed, Embase, Scopus, and Web of Science until June 12th, 2023, aiming to identify studies that assessed the diagnostic performance of the ROSIER scale in detecting strokes and TIAs among individuals with suspected stroke symptoms.

Results: Data extracted from 34 studies were analyzed, demonstrating that the ROSIER score, with a cut-off value of ≥ 1, has sensitivity of 0.89 (95% confidence interval (CI): 0.86–0.92), specificity of 0.76 (95% CI: 0.69–0.81), diagnostic odds ratio (DOR) of 25.41 (95% CI: 17.2–37.54), and area under the curve (AUC) of 0.91 (95% CI: 0.85–0.90) in detection of strokes and TIAs. Meta-regression subgroup analysis revealed variations in sensitivity and specificity based on different settings and assessors. Sensitivity was higher in pre-hospital settings when the test was administered by emergency medical services (EMS) and emergency department (ED) paramedic staff, whereas specificity was higher in emergency department settings and when physicians and neurologists conducted the test.

Conclusion: A moderate level of evidence shows that the ROSIER scale is considered an excellent tool for identifying strokes and TIAs. As a valid method for identifying strokes, it holds applicability across diverse settings and can be effectively used by assessors with different specialties.

Intra-Operative Adjunctive Magnesium Sulfate in Pain Management of Total Knee Arthroplasty; a Systematic Review and Meta-analysis

Amirali Azimi, Fatemeh-sadat Tabatabaei, Amirfarbod Azimi, Hamid Mazloom, Mohammad Mehdi Foruzanfar, Nastaran Sadat Mahdavi (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e58

Introduction: There has been growing interest in the potential role of adjunctive magnesium sulfate in improving pain management. This systematic review and meta-analysis aimed to assess the effect of intra-operative adjunctive magnesium sulfate on pain management and opioid consumption in total knee arthroplasty (TKA).

Methods: A comprehensive search was conducted in Medline, Embase, Scopus, Web of Science, and Cochrane Library databases, covering studies up to April 2023. The extracted data included pain management outcomes, opioid consumption, and adverse effects from the selected studies. Standardized mean differences (SMDs) were calculated for continuous outcomes, while risk ratios (RRs) were calculated for dichotomous outcomes. Meta-analysis was conducted employing random-effects models in STATA 17.

Results: In this meta-analysis of 8 randomized controlled trials involving 536 patients, adjunctive magnesium sulfate in TKA was found to significantly reduce opioid consumption during the first 24 hours after operation (SMD: -1.88, 95% confidence interval (CI): [-3.66 to -0.10]; p = 0.038). It also resulted in lower pain scores at rest 24 hours after surgery (SMD: -1.53, 95% CI: [-2.70 to -0.37]; p = 0.010). There were no significant differences in time to first rescue analgesic and adverse effects between the groups. The included studies were assessed to have low to high levels of risk of bias.

Conclusion: This study presents evidence at low to moderate levels supporting the use of intra-operative adjunctive magnesium sulfate in TKA for improved pain management and reduced opioid consumption. However, further research is needed to address the heterogeneity and to explore optimal dosing regimens and routes of administration to maximize the benefits of magnesium sulfate in TKA.

Non-Pharmacologic Interventions in COVID-19 Pandemic Management; a Systematic Review

Koorosh Etemad, Parisa Mohseni, Saeideh Shojaei, Seyed Ali Mousavi, Shakiba Taherkhani, Fatemeh Fallah Atatalab, Hadis Ghajari, Seyed Saeed Hashemi Nazari, Manoochehr Karami, Manoochehr Karami, Neda Izadi, Mahmoud Hajipour (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e52

Introduction: Different countries throughout the world have adopted non-pharmacologic interventions to reduce and control SARS - CoV-2. In this systematic approach, the impact of non-pharmacologic interventions in management of COVID-19 pandemic was assessed.

Methods: Following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, systematic search was carried out on the basis of a search strategy on PubMed, Web of Science, Scopus, and WHO databases on COVID-19. The impact of travel ban, personal protective equipment, distancing, contact tracing, school closure, and social distancing and the combined effect of interventions on COVID-19 were assessed.

Results: Of the 14,857 articles found, 44 were relevant. Studies in different countries have shown that various non-pharmacological interventions have been used during the COVID-19 pandemic. The travel ban, either locally or internationally in most of the countries, movement restriction, social distancing, lockdown, Personal Protective Equipment (PPE), quarantine, school closure, work place closure, and contact tracing had a significant impact on the reduction of mortality or morbidity of COVID-19.

Conclusion: Evidence shows that the implementation of non-pharmacologic interventions (NPIs), for example, social distancing, quarantine, and personal protective equipment’s are generally effective and the best way to prevent or reduce transmission. However, this study suggests that the effectiveness of any NPI alone is probably limited, thus, a combination of various actions, for example, social distancing, isolation, and quarantine, distancing in the workplace and use of personal protective equipment, is more effective in reducing COVID-19.

Point-Of-Care Ultrasonography for Identification of Skin and Soft Tissue Abscess in Adult and Pediatric Patients; a Systematic Review and Meta-Analysis

Erfan Rahmani, Ehsan Fayyazishishavan, Arian Afzalian, Sanaz Varshochi, Reza Amani-Beni, Seyed-Amirabbas Ahadiat, Zeynab Moshtaghi, Seyyed-Ghavam Shafagh, Roya Khorram, Elnaz Asadollahzade, Raihaneh Atbaei, Mohammad Saeed Kahrizi, Atoosa Rahbari, Negar Baharlouie, Farzaneh Mostanbet, Bahamin Amirabadiquchani, Moein Kiani, Mozhdeh Memarizadeh, Shahin Keshtkar Rajabi, Reza Barati, Hengame Hajinouri, Shahrzad Najafi, Zeynab Abdollahi, Nahid Dadashzadehasl, Atousa Moghadam Fard, Mozhgan Afshar, Atefeh Abedi, Sara Saeidi, Adeleh Mansourirad, Pedram Emami Sharezaei, Sepideh Shah Hosseini, Zahra Rostami Ghotbabadi, Reza Vafadar, Roozbeh Roohinezhad, Nogol Ghalamkarpour, Mehrdad Farrokhi (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e49

Introduction: Differentiating the soft tissue abscess from other types of skin and soft tissue infections (SSTIs) poses a particular challenge because they have similar physical evaluation findings, but each disease has a different course, outcome, and treatment. This meta-analysis aimed to investigate the diagnostic accuracy of point-of-care ultrasonography for diagnosis of soft tissue abscess in the emergency departments.

Methods: A comprehensive literature search of MEDLINE, Scopus, Web of Science, Embase, and Google Scholar, from inception to January 2023, was conducted to identify relevant studies investigating the diagnostic performance of point-of-care ultrasonography for identification of abscess. Methodological quality of the included studies was assessed using a revised tool for the quality assessment of diagnostic accuracy studies (QUADAS-2).

Results: The pooled estimates of diagnostic parameters of ultrasonography for diagnosis of abscess were as follows: sensitivity, 0.93 (95% CI: 0.92–0.94); specificity, 0.87 (95% CI: 0.85–0.89), and the area under the summary receiver-operating characteristic (SROC), 0.95. The pooled sensitivity, specificity, and area under the SROC of studies in adult patients were 0.98 (95% CI: 0.92–1), 0.92 (95% CI: 0.86–0.95), and 0.99, respectively. The pooled sensitivity, specificity, and area under the SROC of studies in pediatric patients were 0.9 (95% CI: 0.87–0.92), 0.78 (95% CI: 0.73–0.82), and 0.91, respectively.

Conclusion: Our meta-analysis demonstrated that the point-of-care ultrasonography has excellent diagnostic value for the abscess in the emergency department. Furthermore, we found that the diagnostic performance of point-of-care ultrasonography for diagnosis of abscess was higher for adult cases than for pediatric patients.

HEART versus GRACE Score in Predicting the Outcomes of Patients with Acute Coronary Syndrome; a Systematic Review and Meta-Analysis

Ali Kabiri, Pantea Gharin, Seyed Ali Forouzannia, Koohyar Ahmadzadeh, Reza Miri, Mahmoud Yousefifard (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e50

Introduction: Several scoring systems have been proposed to predict the outcomes of patients with ischemic heart disease. Global Registry of Acute Coronary Events (GRACE) and History, ECG, Age, Risk Factors, and Troponin (HEART) scores are two of the more widely used risk prediction tools in patients with acute coronary syndrome (ACS). The present systematic review and meta-analysis aimed to compare the value of GRACE and HEART scores in the outcome prediction of ACS patient.

Method: The online databases of Medline, Embase, Web of Science, and Scopus were search until September 2022 for articles directly comparing GRACE and HEART scores value in prediction of outcome in patients with ACS. GRACE score cut-offs were categorized into two groups of less than and equal to 100 and more than 100, and HEART score cut-offs were categorized into three groups of less than 4, equal to 4, and more than 4. Investigated outcomes were major adverse cardiovascular events (MACE), acute myocardial infraction (AMI) and all-cause mortality.

Results: 25 articles were included. The sensitivity and specificity of the GRACE score for prediction of MACE were 0.96 and 0.26 for cut-offs of ≤ 100, and 0.58 and 0.69 for cut-offs of >100, respectively. The sensitivity and specificity of the HEART score for prediction of MACE were 0.99 and 0.16 for cut-offs less than 4, 0.93 and 0.47 for equal to 4, and 0.77 and 0.78 for cut-offs greater than 4. GRACE score was shown to be predictive of AMI with sensitivity and specificity of 0.95 and 0.29, respectively. The analysis for the value of HEART score in the prediction of AMI a sensitivity and specificity of 0.94 and 0.48, respectively. The risk scores were not found to be suitable predictors of all-cause mortality.

Conclusion: The results demonstrated the low specificity of GRACE and HEART scores in predicting the MACE, AMI and all-cause mortality, irrespective of the utilized cut-off. Considering the acceptable sensitivity of two scores in predicting the MACE and AMI, these scores were more suitable to be used as a rule-out tool for identification of ACS patients with low risk of developing adverse outcomes.

Prevalence of Compartment Syndrome and Disseminated Intravascular Coagulation following Rhabdomyolysis; a Systematic Review and Meta-Analysis

Bardia Danaei, Ali Sharifi, Hamid Mazloom, Iraj Najafi, Mehri Farhang Ranjbar, Saeed Safari (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e55

Introduction: Rhabdomyolysis (RM) may cause some complications such as compartment syndrome and disseminated intravascular coagulation (DIC), which can affect its prognosis. This systematic review and meta-analysis aimed to investigate the prevalence of the mentioned complications following RM.

Methods: Medline, Embase, and Scopus databases were searched using keywords related to compartment syndrome, DIC, and rhabdomyolysis with appropriate combination. Cohort and cross-sectional studies that conducted research on the prevalence of compartment syndrome and DIC in patients with RM were included in the present study. The desired data were extracted from the included studies and meta-analysis was conducted on them to calculate pooled prevalence of these complications.

Results: Twenty articles were included in our systematic review. The rate of compartment syndrome reported in these studies ranged from 0 to 30.7%. Our meta-analysis revealed the pooled prevalence of 4% (95% confidence interval (CI): 2.20 to 7.40) for compartment syndrome in these studies. The pooled prevalence of this complication was 7.1% (95% CI: 2.90 to 16.00) among patients with severe RM and 4.4% (95% CI: 1.80 to 10.00) in traumatic RM. The rate of DIC reported in the included studies ranged from 0 to 40.47%. Our meta-analysis showed the pooled prevalence of 8.3% (95% CI: 03.90 to 16.50) for this complication among RM patients.

Conclusion: We reported the rates of compartment syndrome and DIC in RM patients based on rhabdomyolysis etiologies through an epidemiologic systematic review and meta-analysis. The rate of compartment syndrome was slightly higher in patients with severe RM and its rate in patients with traumatic RM was close to the overall rate of compartment syndrome. 

Canadian C-spine Rule versus NEXUS in Screening of Clinically Important Traumatic Cervical Spine Injuries; a systematic review and meta-analysis

Mohammadhossein Vazirizadeh-mahabadi1, Mobina Yarahmadi (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e5

Introduction: The Canadian C-spine Rule (CCR) and the National Emergency X-Radiography Utilization Study (NEXUS) are two criteria designed to rule-out clinically important traumatic cervical Spinal Cord Injury (SCI). In this systematic review and meta-analysis, we reviewed the articles comparing the performance of these two models.

Methods: Search was done in Medline, Embase, Scopus and Web of Science until June 2022. Observational studies with direct comparison of CCR and NEXUS criteria in detection of clinically important cervical SCI were included. Two independent reviewers screened the relevant articles and summarized the data. Certainty of evidence was assessed based on QUADAS-2. Data were recorded as true positive, true negative, false positive, and false negative. Then, using “diagma” package and applying weighted random effect model, area under the receiver operating characteristic (ROC) curve (AUC), sensitivity, specificity, negative likelihood ratio, positive likelihood ratio, and diagnostic odds ratio (DOR) were calculated with 95% confidence interval (95% CI).

Results: We included 5 studies with direct comparison. Area under the ROC curve of NEXUS in screening of patients with clinically important cervical SCI was 0.708 (95% CI: 0.647 to 0.762). Pooled sensitivity and specificity of NEXUS criteria in screening of patients with clinically important cervical SCI were 0.899 (95% CI: 0.845 to 0.936) and 0.398 (95% CI: 0.315 to 0.488). The positive and negative likelihood ratios of NEXUS were 1.494 (95% CI: 1.146 to 1.949) and 0.254 (95% CI: 1.155 to 1.414), respectively. Diagnostic odds ratio of NEXUS was 5.894 (95% CI: 3.372 to 10.305). Furthermore, area under the ROC curve of CCR in screening of clinically important cervical SCI was 0.793 (95% CI: 0.657 to 0.884). Meta-analysis results showed that pooled sensitivity of CCR criteria in screening of patients with clinically important cervical SCI was 0.987 (95% CI: 0.957 to 0.996) and specificity was 0.167 (95% CI: 0.073 to 0.336). The positive and negative likelihood ratios of CCR were 1.184 (95% CI: 0.837 to 1.675) and 0.081 (95% CI: 0.021 to 0.308), respectively. Diagnostic odds ratio of CCR was 14.647 (95% CI: 3.678 to 58.336).

Conclusion: Based on studies, both CCR and NEXUS were sensitive rules that have the potential to reduce unnecessary imaging in cervical spine trauma patients. However, the low specificity and false-positive results of both of these tools indicate that many people will continue to undergo unnecessary imaging after screening of cervical SCI using these tools. In this meta-analysis, CCR appeared to have better screening accuracy.

Value of N-Terminal Pro-Brain Natriuretic Peptide for Embolic Events Risk Prediction in Patients with Atrial Fibrillation; a Systematic Review and Meta-Analysis

Koohyar Ahmadzadeh, Amirali Hajebi, Hamzah Adel Ramawad, Yaser Azizi, Mahmoud Yousefifard (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e8

Introduction: A comprehensive conclusion has yet to be made about the predictive value of serum N-terminal pro-brain natriuretic peptide (NT-proBNP) for stroke/systemic embolic events (SEE) in patients with atrial fibrillation (AF). This study aims to review the evidence for evaluating the value of NT-proBNP in predicting the risk of stroke/SEE in patients with AF through a systematic review and meta-analysis.

Method: Two independent reviewers screened all relevant studies that were retrieved from the database of Medline, Embase, Scopus, and Web of Science until December 7th, 2021. The predictive value of NT-proBNP in the prediction of stroke/SEE was recorded as hazard ratio (HR) and 95% confidence interval (95% CI).

Results: Nine articles (38,093 patients, 3.10% stroke/SEE) were included in our analysis. There was no publication bias in these studies (P=0.320). Our analysis showed that NT-proBNP can be a good predictor of stroke/SEE risk in AF patients, even at different cut-off values (HR=1.76; 95% CI: 1.51, 2.02; P < 0.001). Subgroup analysis showed that diabetes could have a possible effect on the predictive value of NT-proBNP (meta-regression coefficient = 0.042; P = 0.037).

Conclusion: Measurement of NT-proBNP during the first admission could be used to assess the short- or long-term risk of stroke/SEE in patients with AF. Further studies are needed to evaluate the possible applicability of serum NT-proBNP measurement in the settings in which stroke is the sole outcome of the investigation.

Serum Glial Fibrillary Acidic Protein in Detecting Intracranial Injuries Following Minor Head Trauma; a Systematic Review and Meta-Analysis

Sajjad Ahmadi, Shayan Roshdi Dizaji, Asrin Babahajian, Mohammadreza Alizadeh, Arash Sarveazad, Mahmoud Yousefifard (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e9

Introduction: Developing novel diagnostic and screening tools for exploring intracranial injuries following minor head trauma is a necessity. This study aimed to evaluate the diagnostic value of serum glial fibrillary acidic protein (GFAP) in detecting intracranial injuries following minor head trauma.

Methods: An extensive search was performed in Medline, Embase, Scopus, and Web of Science databases up to the end of April 2022. Human observational studies were chosen, regardless of sex and ethnicity of their participants. Pediatrics studies, report of diagnostic value of GFAP combined with other biomarkers (without reporting the GFAP alone), articles including patients with all trauma severity, defining minor head trauma without intracranial lesions as the outcome of the study, not reporting sensitivity/specificity or any other values essential for computation of true positive, true negative, false positive and false-negative, being performed in the prehospital setting, assessing the prognostic value of GFAP, duplicated reports, preclinical studies, retracted articles, and review papers were excluded. The result was provided as pooled sensitivity, specificity, diagnostic score and diagnostic odds ratio, and area under the summary receiver operating characteristic (SROC) curve with a 95% confidence interval (95% CI).

Results: Eventually, 11 related articles were introduced into the meta-analysis. The pooled analysis implies that the area under the SROC curve for serum GFAP level in minor traumatic brain injuries (TBI) was 0.75 (95% CI: 0.71 to 0.78). Sensitivity and specificity of this biomarker in below 100 pg/ml cut-off were 0.83 (95% CI: 0.78 to 0.89) and 0.39 (95% CI: 0.24 to 0.53), respectively. The diagnostic score and diagnostic odds ratio of GFAP in detection of minor TBI were 1.13 (95% CI: 0.53 to 1.74) and 3.11 (95% CI: 1.69 to 5.72), respectively. The level of evidence for the presented results were moderate.

Conclusion: The present study's findings demonstrate that serum GFAP can detect intracranial lesions in mild TBI patients. The optimum cut-off of GFAP in detection of TBI was below 100 pg/ml. As a result, implementing serum GFAP may be beneficial in mild TBI diagnosis for preventing unnecessary computed tomography (CT) scans and their related side effects.

Monkeypox Disease with a Focus on the 2022 Outbreak; a Narrative Review

Zohreh Tehranchinia, Reza M Robati, Hamideh Moravvej, Mojtaba Memariani, Hamed Memariani (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e19

Monkeypox is a zoonotic disease caused by a double-stranded DNA virus belonging to the genus Orthopoxvirus. Despite being endemic in Central and West Africa, the disease has received relatively little research attention until recent times. As the Coronavirus disease 2019 (COVID-19) pandemic continues to affect the world, the rising number of monkeypox cases in non-endemic countries has further stoked global public health concerns about another pandemic. Unlike previous outbreaks outside Africa, most patients in the present outbreak had no history of travel to the endemic regions. The overwhelming majority of patients were initially identified amongst homosexual men, who had attended large gatherings. Mutations in the coding regions of the viral genome may have resulted in fitness adaptation, enhancement of immune evasion mechanisms, and more efficient transmissibility of the 2022 monkeypox virus. Multiple factors such as diminished cross-protective herd immunity (cessation of smallpox vaccination), deforestation, civil war, refugee displacement, farming, enhanced global interconnectedness, and even climate change may facilitate the unexpected emergence of the disease. In light of the increasing number of cases reported in the present outbreak, healthcare professionals should update their knowledge about monkeypox disease, including its diagnosis, prevention, and clinical management. Herein, we provide an overview of monkeypox, with a focus on the 2022 outbreak, to serve as a primer for clinical practitioners who may encounter the disease in their practice.

Diagnostic Accuracy of Ultrasonography for Detection of Intussusception in Children; a Systematic Review and Meta-Analysis

Erfan Rahmani, Reza Amani-Beni, Yasaman Hekmatnia, Amirhossein Fakhre Yaseri, Seyed-Amirabbas Ahadiat, Parham Talebi Boroujeni, Moein Kiani, Reza Tavakoli, Seyyed-Ghavam Shafagh, Matin Shirazinia, ‏‏Setareh Garousi, Mehran Mottahedi, Mohammad Reza Arzaghi, Sasan Pourbagher Benam, Amir Rigi, Amir Salmani, Zeynab Abdollahi, Fateme Karimzade Rokni, Tara Nikbakht, Saeme Azizi Hassan Abadi, Roozbeh Roohinezhad, Forough Masheghati, Yas Haririan, Bahar Darouei, Ehsan Fayyazishishavan, Niusha Manoochehri-Arash, Mehrdad Farrokhi (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e24

Introduction: The diagnosis of intussusception can be challenging in children due to the fact that the findings of clinical evaluations are nonspecific and most of the patients present with unclear history. Therefore, in this systematic review and meta-analysis, we aimed to investigate the diagnostic accuracy of ultrasonography for detection of intussusception and also compare the efficacy of point-of-care ultrasound (POCUS) with radiologist-performed ultrasound (RADUS).

Methods: Two independent reviewers systematically searched different online electronic databases including MEDLINE, Scopus, Web of Science, Google Scholar, Embase, and Cochrane from inception to December 1, 2022 to identify published papers reporting accuracy of ultrasonography for diagnosis of intussusception. The quality assessment of the included studies was investigated using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 tool.

Results: A total of 1446 records were retrieved in the initial search of databases. After screening the titles, a total of 344 studies were retrieved for the detailed assessment of full-text. Finally, 37 studies were included in qualitative and quantitative analysis. The pooled sensitivity and specificity of ultrasonography for diagnosis of intussusception were 0.96 (95% CI: 0.95-0.97) and 0.97 (95% CI: 0.97-0.98), respectively. The pooled positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 24.57 (95% CI: 8.26-73.03) and 0.05 (95% CI: 0.04-0.08), respectively. The area under the hierarchical summary receiver operating characteristic (HSROC) curve was 0.989. Mete-regression showed that there is no significant difference between diagnostic performance of POCUS and RADUS (p = 0.06 and rDOR (diagnostic odds ratio) = 4.38 (95% CI: 0.92-20.89)).

Conclusion: This meta-analysis shows that ultrasonography has excellent sensitivity, specificity, and accuracy for diagnosis of intussusception in pediatric patients. Moreover, we found that diagnostic performance of POCUS is similar to that of RADUS for diagnosis of intussusception.

Prognostic Value of The Leuko-Glycemic Index in Acute Myocardial Infarction; a Systematic Review and Meta-Analysis

Roxana Sadeghi, Shayan Roshdi Dizaji, Mohammadhossein Vazirizadeh-Mahabadi, Arash Sarveazad, Seyed Ali Forouzannia (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e25

Introduction: In recent years, studies have provided evidence on the prognostic value of the leuko-glycemic index (LGI) in acute myocardial infarction (MI), but there is a lack of consensus. In addition, various reported cut-offs for LGI have raised concern regarding its clinical applicability. So, to conclude, through this systematic review and meta-analysis, we aimed to investigate all available evidence on the prognostic value of LGI in acute MI.

Methods: Two independent researchers summarized records available in the four main databases of Medline (Via PubMed), Embase, Scopus, and Web of Science until 15 Sep 2022. Articles studying the prognostic value of the LGI in acute MI were included. Finally, sensitivity, specificity, prognostic odds ratio, and the area under the curve (AUC) for LGI were analyzed and reported.

Results: Eleven articles were included (3701 patients, 72.1% male). Based on the analyses, AUC, sensitivity, and specificity for LGI in prediction of mortality following acute MI were 0.77 (95% CI: 0.73 to 0.80), 0.75 (95% CI: 0.62 to 0.84), and 0.66 (95% CI: 0.51 to 0.78), respectively. Positive and negative post-test probability of LGI in prediction of mortality were 21% and 5%, respectively. AUC, sensitivity, and specificity for LGI in prediction of major cardiac complications after acute MI were 0.81 (95% CI: 0.77 to 0.84), 0.84 (95% CI: 0.70 to 0.92), and 0.64 (95% CI: 0.49 to 0.84), respectively. Also, the Positive and negative post-test probability of LGI in this regard were 59% and 13%, respectively.

Conclusion: Although the results demonstrated that the LGI could predict mortality and acute cardiac complication after MI, the low post-test probability of LGI in risk stratification of patients raises questions regarding its applicability. Nevertheless, as most of the available studies have been conducted in the Latino/Hispanic population, further evidence is warranted to generalize the validity of this tool to other racial populations. 

Clinical Characteristics, Course, and Outcomes of Vertebral Artery Dissections in the Postpartum Period; a Pooled Analysis of Published Case Reports

Rehab Adel Diab, Nour Shaheen, Abdelrahman Mohamed, Mahmoud Hefnawy, Dilawer Charo, Mostafa Meshref (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e26

Introduction: Vertebral artery dissection (VAD) is a rare, but life-threatening condition. Compared to the general population, pregnant and postpartum women are more likely to develop VAD. Spontaneous arterial dissections have an ambiguous pathophysiology and may be difficult to manage. This study aimed to pool and analyze the data of published cases in this regard.

Methods: We conducted a literature search on February 24, 2022, using MeSH terms of interest in PubMed, Google Scholar, Ovid, Web of Science, and Scopus databases to find studies on VAD following childbirth.

Results: A total of 28 studies were included in this review based on a database search. In the studies, 44 postpartum VAD (PPVAD) patients with a mean age of 34.26 ± 3.5 years were included. It took an average of 24.37± 13.7 days from delivery to dissection. 64% of the patients had developed unilateral dissection and 36% had developed bilateral dissection; 70% reported full recovery, and 9% did not achieve full recovery. The most common symptoms were headaches (89%), neck pain (64%), and hypertension (52%). The most common methods of diagnosis were magnetic resonance imaging (MRI) (64%) and computed tomography (CT) angiography (CTA) scan (66%). Only 8 (18%) cases reported the use of electrocardiography (ECG). The recorded outcomes of the patients with unilateral and bilateral postpartum VAD showed no statistical difference. Most of the included studies recommend early suspension and management for a better prognosis and prevention of complications.

Conclusion: PPVAD is a severe medical condition but most cases were fully recovered after an early and proper antithrombotic plan for each case scenario.

Prognostic Value of CRASH and IMPACT Models for Predicting Mortality and Unfavorable Outcome in Traumatic Brain Injury; a Systematic Review and Meta-Analysis

Hamed Zarei, Mohammadhossein Vazirizadeh-Mahabadi, Hamzah Adel Ramawad, Arash Sarveazad, Mahmoud Yousefifard (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e27

Introduction: The Corticosteroid Randomization After Significant Head injury (CRASH) and the International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) are two prognostic models frequently used in predicting the outcome of patients with traumatic brain injury. There are ongoing debates about which of the two models has a better prognostic value. This study aims to compare the CRASH and IMPACT in predicting mortality and unfavorable outcome of patients with traumatic brain injury.

Method: We performed a literature search using Medline (via PubMed), Embase, Scopus, and Web of Science databases until August 17, 2022. After two independent researchers screened the articles, we included all the original articles comparing the prognostic value of IMPACT and CRASH models in patients with traumatic brain injury. The outcomes evaluated were mortality and unfavorable outcome. The data of the included articles were analyzed using STATA 17.0 statistical program, and we reported an odds ratio (OR) with a 95% confidence interval (95% CI) for comparison.

Results: We included the data from 16 studies. The analysis showed that the areas under the curve of the IMPACT core model and CRASH basic model do not differ in predicting the mortality of patients (OR=0.99; p=0.905) and their six-month unfavorable outcome (OR=1.01; p=0.719). Additionally, the CRASH CT model showed no difference from the IMPACT extended (OR=0.98; p=0.507) and IMPACT Lab (OR=1.00; p=0.298) models in predicting the mortality of patients with traumatic brain injury. We also observed similar findings in the six-month unfavorable outcome, showing that the CRASH CT model does not differ from the IMPACT extended (OR=1.00; p=0.990) and IMPACT Lab (OR=1.00; p=0.570) in predicting the unfavorable outcome in head trauma patients.

Conclusion: Low to very low level of evidence shows that IMPACT and CRASH models have similar values in predicting mortality and unfavorable outcome in patients with traumatic brain injury. Since the discriminative power of the IMPACT Core and CRASH basic models is not different from the IMPACT extended, IMPACT Lab, and CRASH CT models, it may be possible to only use the core and basic models in examining the prognosis of patients with traumatic injuries to the brain.

Late Complications of COVID-19; An Umbrella Review on Current Systematic Reviews

SeyedAhmad SeyedAlinaghi, AmirBehzad Bagheri, Armin Razi, Paniz Mojdeganlou, Hengameh Mojdeganlou, Amir Masoud Afsahi, Arian Afzalian, Parinaz Paranjkhoo, Ramin Shahidi, Pegah Mirzapour, Zahra Pashaei, Mohammad Amin Habibi, Parmida Shahbazi, Sahar Nooralioghli Parikhani, Narjes Sadat Farizani Gohari, Yusuf Popoola, Esmaeil Mehraeen, Daniel Hackett (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e28

Introduction: Several clinical manifestations have been discovered for COVID-19 since the emergence of SARS-CoV-2, which can be classified into early, medium, and long-term complications. However, late complications can be present after recovery from acute COVID-19 illness. The present study aims to comprehensively review the available evidence of late complications related to COVID-19.

Method: A search was conducted, using keywords, through electronic databases, which included Scopus, Web of Science, PubMed, and Embase up to August 29, 2022. Study selection was performed according to a strict inclusion and exclusion criteria. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) checklist was followed, and studies were appraised using the National Institute of Health (NIH) quality assessment and risk of bias tool.

Results: In total, 50 studies were included, and nine distinct COVID-19 late complication categories were identified. A review of these studies revealed that neurologic and psychiatric (n=41), respiratory (n=27), musculoskeletal and rheumatologic (n=22), cardiovascular (n=9), and hepatic and gastrointestinal (n=6) complications were the most prevalent complications of long COVID-19.

Conclusion: Almost all human body systems are affected by late complications of COVID-19 with different severity and prevalence. Fatigue and some other neuropsychiatric symptoms are the most common late complications among long COVID-19 patients. Respiratory symptoms including dyspnea (during exercise), cough, and chest tightness were the next most prevalent long-term complications of COVID-19. Since these complications are persistent and late, being aware of the signs and symptoms is essential for the healthcare providers and patients.

Diagnostic Accuracy of Ottawa Knee Rule for Diagnosis of Fracture in Patients with Knee Trauma; a Systematic Review and Meta-analysis

Seyyed-Morteza Kazemi, Roya Khorram, Ehsan Fayyazishishavan, Reza Amani-Beni, Yas Haririan, Seyed Mehdi Hosseini Khameneh, Erfan Rahmani, Reza Minaei Noshahr, Mahshad Sarikhani, Rana Rahimi, Sara Saeidi, Diba Saeidi, Mehrdad Farrokhi (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e30

Introduction: In order to improve the efficacy of requesting knee radiography and reduce unnecessary radiation exposure, some clinical decision rules have been proposed for the assessment of knee injuries. Among them, the Ottawa Knee Rule (OKR) was considered as one of the best guidelines with several validation studies. Therefore, in this meta-analysis, we aimed to investigate the accuracy of OKR for diagnosis of fracture in patients presenting with knee trauma.

Methods: A systematic search was conducted in PubMed, Web of Science, Scopus, Google Scholar, and EBSCO from inception to September 2022. Quality assessment of the included studies was performed using QUADAS-2 tool. Diagnostic accuracy parameters were analyzed using random-effects model. Statistical analysis was performed using Meta-Disc and Stata softwares.

Results: The meta-analysis of the 18 included studies (6702 patients) showed that the pooled sensitivity and specificity of OKR for diagnosis of fractures were 0.98 (95% CI: 0.96-0.99) and 0.43 (95% CI: 0.42-0.45), respectively. The pooled positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 1.56 (95% CI: 1.39-1.75) and 0.12 (95% CI: 0.05-0.26), respectively. The area under curve (AUC) of the hierarchical summary receiver operating characteristic (HSROC) curve was 0.54.

Conclusion: This meta-analysis indicates that OKR has a high diagnostic performance for diagnosis of fracture, with a pooled sensitivity of 98% and a pooled specificity of 43%. These results propose potential effects of OKR on reduction of unnecessary radiography, time spent in emergency departments, and direct and indirect costs, which should be confirmed using high-quality studies in the future.

Effect of Oral Care with Povidone-Iodine in the Prevention of Ventilator-Associated Pneumonia; a Systematic Review and Meta-Analysis

Amir Emami Zeydi, Arman Parvizi, Soudabeh Haddadi, Samad Karkhah, Seyed Javad Hosseini , Amirabbas Mollaei, Mahbobeh Firooz , Shahin Ramezani , Joseph Osuji, Pooyan Ghorbani Vajargah , Shadi Dehghanzadeh (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e31

Introduction: Ventilator-associated pneumonia (VAP) is one of the most common nosocomial infections affecting one-third of patients with mechanical ventilation. This study aimed to synthesize available evidence regarding the effect of treatment with povidone-iodine (PI) among adult patients admitted to intensive care units (ICUs) for the prevention of VAP.

Methods: An extensive search was conducted in online databases, including PubMed, Web of Science and Scopus, from the earliest records until January 1, 2023. STATA software v14 was used for statistical analysis. Publication bias was assessed via funnel plot, Begg's and Egger's tests. A P-value less than 0.1 was considered statistically significant for publication bias value.

Results: Four studies were included in the meta-analysis. Three studies showed rhat PI decreased  VAP compared to the placebo group, but it was not statistically significant (RR: 0.61, 95%CI: 0.25 to 1.47, Z=1.10, P=0.27, I2:71.5%). One study compared the effect of PI with chlorhexidine on the rate of VAP, the difference between which was not statistically significant (RR: 1.50, 95%CI: 0.46 to 4.87, Z=0.67, P=0.50, I2:0). Two studies demonstrated that the use of PI intervention compared to placebo decreased the average length of stay in ICU; however, it was not statistically significant (WMD: -0.35, 95%CI:-3.90 to 3.20, Z=0.19, P=0.85, I2:0). Also, three studies showed that using PI had almost no effect on mortality rate compared to placebo (RR: 1.05, 95%CI: 0.66 to 1.53, Z=0.8, P=0.27, I2:29.0%).Conclusion: More rigorously designed randomized clinical trials and further evidence are required to make a better decision/comparison about using PI as a suitable choice for preventing VAP among adult patients admitted to the ICU.

The Aspects of Running Artificial Intelligence in Emergency Care; a Scoping Review

Mohsen Masoumian Hosseini, Seyedeh Toktam Masoumian Hosseini, Karim Qayumi, Soleiman Ahmady, Hamid Reza Koohestani (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e38

Introduction: Artificial Inteligence (AI) application in emergency medicine is subject to ethical and legal inconsistencies. The purposes of this study were to map the extent of AI applications in emergency medicine, to identify ethical issues related to the use of AI, and to propose an ethical framework for its use.

Methods: A comprehensive literature collection was compiled through electronic databases/internet search engines (PubMed, Web of Science Platform, MEDLINE, Scopus, Google Scholar/Academia, and ERIC) and reference lists. We considered studies published between 1 January 2014 and 6 October 2022. Articles that did not self-classify as studies of an AI intervention, those that were not relevant to Emergency Departments (EDs), and articles that did not report outcomes or evaluations were excluded. Descriptive and thematic analyses of data extracted from the included articles were conducted.

Results: A total of 137 out of the 2175 citations in the original database were eligible for full-text evaluation. Of these articles, 47 were included in the scoping review and considered for theme extraction. This review covers seven main areas of AI techniques in emergency medicine: Machine Learning (ML) Algorithms (10.64%), prehospital emergency management (12.76%), triage, patient acuity and disposition of patients (19.15%), disease and condition prediction (23.40%), emergency department management (17.03%), the future impact of AI on Emergency Medical Services (EMS) (8.51%), and ethical issues (8.51%).

Conclusion: There has been a rapid increase in AI research in emergency medicine in recent years. Several studies have demonstrated the potential of AI in diverse contexts, particularly when improving patient outcomes through predictive modelling. According to the synthesis of studies in our review, AI-based decision-making lacks transparency. This feature makes AI decision-making opaque.

Needle Direction and Distance of Arteriovenous Fistula Cannulation in Hemodialysis Adequacy; a Systematic Review and Meta-Analysis

Samad Karkhah, Majid Pourshaikhian, Pooyan Ghorbani Vajargah , Morteza Zaboli Mahdiabadi, Amirabbas Mollaei, Saman Maroufizadeh, Seyed Javad Hosseini, Joseph Osuji, Mohammad Taghi Moghadamnia (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e39

Introduction: This systematic review and meta-analysis aimed to summarize the evidence regarding the impact of needle direction and distance of arteriovenous fistula (AVF) cannulation on KT/V (where k is the dialyzer urea clearance, t, the duration of dialysis, and V, the volume of distribution of urea) and access recirculation (AR) as hemodialysis (HD) adequacy criteria.

Methods: A comprehensive systematic search was performed on international and domestic electronic databases from the earliest to June 4, 2022 using keywords. Analysis was performed in STATA software v.14.

Results: Three randomized control trials (RCTs) and four non-RCT articles were included in the final review. Six studies reported the effects of direction, while four mentioned the effects of distances of AVF cannulation on outcomes of HD adequacy based on KT/V or AR. Results of three non-RCT studies showed that retrograde direction decreased KT/V more than antegrade direction (ES: 0.44, 95% CI: -0.38 to 1.27). Two non-RCT studies showed that antegrade decreased AR compared to the retrograde direction (ES: -0.64, 95%CI: -1.94 to 0.67). However, the results of two RCTs indicated uncertainty about this issue. Two of the four studies suggested that a distance of 5 cm or more in arterial and venous needles had greater adequacy than a distance of less than 5 cm. However, other studies did not confirm this finding.

Conclusion: Overall comparison of the results qualitatively and quantitatively indicated uncertainty about the effects of direction and distance of AVF cannulation on HD adequacy outcomes. More studies with high-quality designs, such as RCTs, are required to better understand and adjudicate the effects of needle direction and distance of AVF cannulation on HD adequacy outcomes.

The value of Coronary Artery Disease – Reporting and Data System (CAD-RADS) in Outcome Prediction of CAD Patients; a Systematic Review and Meta-analysis

Koohyar Ahmadzadeh, Shayan Roshdi Dizaji, Mohammad Kiah, Mohamad Rashid, Reza Miri, Mahmoud Yousefifard (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e45

Introduction: Coronary computed tomographic angiography (CCTA) reporting has traditionally been operator-dependent, and no precise classification is broadly used for reporting Coronary Artery Disease (CAD) severity. The Coronary Artery Disease Reporting and Data Systems (CAD-RADS) was introduced to address the inconsistent CCTA reports. This systematic review with meta-analysis aimed to comprehensively appraise all available studies and draw conclusions on the prognostic value of the CAD-RADS classification system in CAD patients.

Method: Online databases of PubMed, Embase, Scopus, and Web of Science were searched until September 19th, 2022, for studies on the value of CAD-RADS categorization for outcome prediction of CAD patients.

Results: 16 articles were included in this systematic review, 14 of which had assessed the value of CAD-RADS in the prediction of major adverse cardiovascular events (MACE) and 3 articles investigated the outcome of all-cause mortality. Our analysis demonstrated that all original CAD-RADS categories can be a predictor of MACE [Hazard ratios (HR) ranged from 3.39 to 8.63] and all categories, except CAD-RADS 1, can be a predictor of all-cause mortality (HRs ranged from 1.50 to 3.09). Moreover, higher CAD-RADS categories were associated with an increased hazard ratio for unfavorable outcomes among CAD patients (p for MACE = 0.007 and p for all-cause mortality = 0.018).

Conclusion: The evidence demonstrated that the CAD-RADS classification system can be used to predict incidence of MACE and all-cause mortality. This indicates that the implementation of CAD-RADS into clinical practice, besides enhancing the communication between physicians and improving patient care, can also guide physicians in risk assessment of the patients and predicting their prognosis.

Case Report

Esophageal Foreign Body Missed Diagnosis; an Analysis of 12 Cases

Xin Yan, Guoping Dai (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e65

Missed diagnosis of foreign bodies in esophagus occasionally results in adverse consequences for patients. This study aimed to analyze the clinical characteristics of esophageal foreign body missed diagnosis in 12 cases. Among the 12 patients, 7 didn't undergo esophagus-related examination due to mild pain; One case didn't report a clear history of swallowing foreign bodies. For one case, computed tomography (CT) examination had not reached the esophageal foreign body level. Two cases were missed diagnosis because the foreign bodies were too tiny to develop clearly on CT. One case showed foreign body in esophagus during initial CT examination, but after subsequent gastroscopy, no foreign body was found. Among the 12 patients, 7 had esophageal perforation, 1 of which developed a neck abscess, and 1 had peri-esophageal abscess. It seems that, if foreign bodies in the pharynx or esophagus are suspected and no foreign bodies are found in the laryngoscope, chest CT scan is necessary. It is best to perform examination of full-length esophagus and pharynx, because foreign bodies may exist in the post-cricoid region or the deep part of the pyriform sinus, especially in older cases with longer retention times.

Posterior Lingual Abscess; Report of Two Cases

Miguel Saro- Buendía, Pedro Suárez Urquiza, Judit Amigo González, Maria José Lesmas Navarro, Miguel Mazón, Miguel Armengot Carceller (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e18

The lingual abscess is rare due to several protective mechanisms against infection in this location. Concretely, the abscess in the base of the tongue (posterior lingual abscess) is even more exceptional. Its prompt detection is crucial to avoid potentially fatal airway complications. To familiarize physicians with this condition, we report 2 cases of posterior lingual abscess. Both were referred to our emergency department due to minor oropharyngeal complaints. Finally, both were diagnosed and required surgical drainage. The clinical evolution was successful: both were discharged in less than 72 hours and follow-up one week later confirmed clinical recovery.

Acute Hepatitis Associated with Intake of Pistacia Vera L. Bud Tea; a Case Report

Kazım Ersin Altınsoy, Mehmet Murat Oktay (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e35

In this study, a patient who developed acute hepatitis due to drinking Pistacia vera L. bud tea is presented. A twenty-eight-year-old woman who had just come out of the postpartum period applied to our clinic with complaints of nausea, vomiting, loss of appetite and weakness. Blood serum alanine aminotransferase and aspartate aminotransferase levels were increased. All serological tests were negative for viral hepatitis and autoimmune diseases. She had been drinking an herbal tea containing Pistacia vera L. bud every day for four weeks to increase milk production. Three weeks after discontinuation of herbal tea, liver enzymes returned to normal. Based on our knowledge, this is probably the first hepatitis report due to the use of an herbal tea containing Pistacia vera L. bud.

Photo Quiz

An Adult Female with Periumbilical Pain and Intractable Vomiting; a Photo quiz

Hamzah Adel Ramawad, Amirmohammad Toloui, Adelaide Viguri (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e7

A 25-year-old female with no significant past medical history presented to the emergency room with complaints of worsening, sharp, periumbilical pain for two days, with an intensity of 8 out of 10 based on the visual analogue scale.  She complained of fever, nausea, anorexia, and multiple episodes of non-bloody, non-bilious emesis.  The patient appeared unwell and diaphoretic.  Her vital signs were as follows, blood pressure of 108/66 mmHg, heart rate of 106 beats/minute and body temperature of 39.3°C. Physical examination showed a distended abdomen with localized tenderness and guarding in the periumbilical region.  A point-of-care ultrasound (POCUS) of the abdomen did not reveal any free fluid. Laboratory testing, which included electrolytes, complete blood count, and renal and liver function revealed no significant abnormalities. Pregnancy test was negative, and urinalysis was unremarkable. The findings of oral and intravenous contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis are shown in figures 1a and 1b.

An 85-Year-Old Man with Gradual Decrease in the Level of Consciousness and Vomiting; a Photo Quiz

Talayeh Mirkarimi, Mohammad Salek (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e37

An 85-year-old male was brought to emergency department (ED) from a skill nursing facility with gradual onset of lethargy and vomiting from a week ago. No clear history of head trauma and coagulopathy or using of anticoagulant agents. His past medical history included mild cognitive impairment (MCI) and diabetes mellitus which treated by oral agent. On general examination the patient looked underweight with body mass index (BMI) about 17. Neither specific stationary position of the limbs nor any spontaneous motor behavior was detected. The patient’s vital signs at admission to ED were: Blood pressure: 140/60 mmHg, pulse rate: 82 beats/minute, oxygen saturation: 95%, Respiratory Rate: 16/minute, bedside blood-glucose measurement: 268 mg/dl. The patient was afebrile. On neurologic examination in ED Glasgow coma scale (GCS) was 10/15 (eye: 3, motor: 5, verbal: 2). Mucosal membranes were dry and patient seemed to be dehydrated. Pupils were equal but had poor reaction to light. Oculocephalic maneuver, corneal reflex and gag reflex were intact. There was slight decrease in muscle tones in lower limbs. Plantar reflex in both sides seems upright. Arm and Leg dropping test showed equal motor response and deep tendon reflexes (DTR) seemed diminished in both sides. Laboratory tests included: leukocyte count: 12800/mm3 with 85% segmented neutrophils, hemoglobin: 14.1 g/dl, platelet: 268000/microliter, glucose: 234 mg/dl, sodium: 141 mEq/L, potassium: 5.1 mEq/L, Blood Urea Nitrogen (BUN): 36 mg/dl, serum creatinine: 1.3 mg/dl and international normalized ratio (INR) of 1.24. The patient underwent brain computed tomography (CT) scan without contrast materials which is showed in figure 1. What is your diagnosis?


Journal Citation Report 2023 of Emergency Medicine Journals; New Players in the Impact Factor Ranking

Saeed Safari, Mahmoud Yousefifard (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e54

Commenced from 1975 and calculated based on the number of overall journal citations in a year divided by the number of citable publications in the preceding two years, Journal Impact Factor (JIF) became a convenient and conventional proxy to appraise a journal's trustworthiness and its scholarly impact in a given field (1).

Analysis of articles in the Journal of Archives of Academic Emergency Medicine in 2022

Somayeh Saghaei Dehkordi, Mehrnoosh Yazdanbakhsh (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e3

In 2022, Archives of Academic Emergency Medicine (AAEM) has published 90 articles, all of which are indexed by SCOPUS, Web of Sciences, PubMed and some other databases. They have been authored by more than four hundred researchers from various countries, including but not limited to the United States, Japan, Korea, Canada, Ghana, France, Norway, India, China, Thailand, Malaysia, Pakistan, Greece, Viet Nam and Iran. In this editorial, we intend to provide an overview of the journal’s flow in 2022, like we did in 2021 (1), so that we can identify our strengths and weaknesses and provide a brief report on our performance to readers and authors, which they might find useful in becoming more familiar with the journal. This article could help the authors who are interested in publishing with us to become more familiar with the journal’s aim and scope, and also the editorial priorities and preferences.


Enhancing Emergency Response through Artificial Intelligence in Emergency Medical Services Dispatching; a Letter to Editor

Payam Emami, Karim Javanmardi (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e60

The emergency medical dispatcher (EMD) serves as a crucial link between individuals in need of emergency medical assistance and the emergency medical services (EMS) resource delivery system. Through their expertise and training, EMDs are able to accurately assess emergency situations, provide appropriate guidance over the phone, and dispatch the necessary EMS personnel to the scene. With adequate training, program management, supervision, and medical guidance, the EMD can accurately assess the caller's needs, choose an appropriate response approach, furnish relevant information to responders, and offer suitable assistance and guidance to patients through the caller. By diligently adhering to a written and medically approved EMD protocol, informed decisions regarding EMS responses can be made in a reliable, replicable, and fair manner (1, 2).

Preventing Medical Errors Using mm-Wave Technology; a Letter to the Editor

Andreas G. Siamarou (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e64

About 795,000 people die or are permanently disabled each year due to diagnostic errors and related harms across clinical settings, according to estimates based on nationally representative disease incidence data for 2012 to 2014 (1). Studies show that the number of medical errors is increasing annually (2). This undergoing research study has its impact on improving human healthcare and reducing diagnostic errors due to fast, accurate, and robust data storage, transmission, and analysis with the use of information technology (IT) (3).

Piperonylbutoxide as a Dubious Cause of Cardiac Manifestations in Pyrethroid Insecticide Poisoning; a Letter to Editor

Foroozan Faress, Maryam Ameri, Maryam Vasheghani Farahani, Sayed Mahdi Marashi (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e10

There is little evidence regarding pyrethroid poisoning manifesting with cardiac problems in the literature. Many authors, however, adopted that pyrethroids have a direct effect on heart tissue and can cause cardiotoxicity. Interestingly, no experimental studies have yet determined its mechanism of toxicity on cardiac muscle cells. This letter aims to describe the probable cause of clinical manifestations attributed to piperonylbutoxide, an ignored ingredient in pesticide poisoning, which is added to many pesticide products to increase their insecticidal potency. We think that cardiac manifestations in some cases of pyrethroid poisoning are due to the concomitant piperonylbutoxide toxicity and its possible effect on norepinephrine release from adrenal gland, which might explain changes in cardiac findings. Thus, it is necessary for all clinical toxicologists to determine suspicious ingredients when they are facing a doubtful manifestation.

Modification of Standard Operating Procedures at the Emergency Department in Brunei During the Second-Wave Outbreak of COVID-19; a Letter to Editor

Shehryar Orakzai, Linawati Jumat, Faiza Alam (Author)

Archives of Academic Emergency Medicine, Vol. 11 No. 1 (2023), 15 November 2022, Page e36

Following 457 days without local transmission, the second wave of COVID-19 hit Brunei Darussalam in August 2021. This warranted the Emergency Department (ED) at Raja-Isteri-Pengiran-Anak-Saleha Hospital to revise standard operating procedures (SOPs). Emergency Department Operations Centre was re-activated, managing ED operations, logistics, personal protective equipment (PPE) provisions, and communication with other Health Facility operation centers.